Healthcare Provider Details

I. General information

NPI: 1659284685
Provider Name (Legal Business Name): MIND INTERVENTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 PROVIDENCE BLVD STE R1142
DELTONA FL
32725-7363
US

IV. Provider business mailing address

1235 PROVIDENCE BLVD STE R1142
DELTONA FL
32725-7363
US

V. Phone/Fax

Practice location:
  • Phone: 407-492-4917
  • Fax:
Mailing address:
  • Phone: 407-492-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMILAH MALIKAH TULLOCH
Title or Position: PSYCHIATRIC NURSE PRACTITIONER/OWNE
Credential: NP
Phone: 407-492-4917