Healthcare Provider Details

I. General information

NPI: 1285230185
Provider Name (Legal Business Name): MIND REVIVE PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 DRANE FIELD RD STE 103
LAKELAND FL
33811-1259
US

IV. Provider business mailing address

4313 S FLORIDA AVE # 1090
LAKELAND FL
33813-1654
US

V. Phone/Fax

Practice location:
  • Phone: 407-602-3380
  • Fax: 833-410-2620
Mailing address:
  • Phone: 407-602-3380
  • Fax: 833-410-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. MARCUS L ROBINSON
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP-BC
Phone: 407-602-3380