Healthcare Provider Details

I. General information

NPI: 1316862154
Provider Name (Legal Business Name): REVITALIZE MENTAL HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 S EATON ST STE B
BALTIMORE MD
21224-2525
US

IV. Provider business mailing address

307 S EATON ST STE B
BALTIMORE MD
21224-2525
US

V. Phone/Fax

Practice location:
  • Phone: 443-354-2162
  • Fax: 443-354-2162
Mailing address:
  • Phone:
  • Fax: 443-354-2162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TASHA NICOLE OUTLAW
Title or Position: CEO
Credential:
Phone: 443-354-2162