Healthcare Provider Details

I. General information

NPI: 1295295178
Provider Name (Legal Business Name): NORTH FLORIDA REGIONAL PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 NW 64TH TER STE B
GAINESVILLE FL
32605-4256
US

IV. Provider business mailing address

2101 NE 2ND ST APT 114
GAINESVILLE FL
32609-8626
US

V. Phone/Fax

Practice location:
  • Phone: 615-372-5426
  • Fax:
Mailing address:
  • Phone: 352-792-8069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAVEN SHENETTE MAYES
Title or Position: OPTOMETRIST
Credential: ONA
Phone: 352-792-8069