Healthcare Provider Details

I. General information

NPI: 1043182280
Provider Name (Legal Business Name): MIND REVIVAL PSYCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 S STONY ISLAND AVE # 7
CHICAGO IL
60649-2806
US

IV. Provider business mailing address

7201 S STONY ISLAND AVE # 7
CHICAGO IL
60649-2806
US

V. Phone/Fax

Practice location:
  • Phone: 773-690-5300
  • Fax: 870-201-4835
Mailing address:
  • Phone: 773-690-5300
  • Fax: 870-201-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. EBONIE WILLIAMS
Title or Position: NP/OWNER
Credential: NP
Phone: 708-715-2035