Healthcare Provider Details

I. General information

NPI: 1033085535
Provider Name (Legal Business Name): REVIVAL PSYCHIATRY AND WELLNESS SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2059 BALTIMORE BLVD
FINKSBURG MD
21048-1301
US

IV. Provider business mailing address

2059 BALTIMORE BLVD STE B
FINKSBURG MD
21048-1301
US

V. Phone/Fax

Practice location:
  • Phone: 443-410-6131
  • Fax: 410-941-2766
Mailing address:
  • Phone: 443-410-6131
  • Fax: 410-941-2766

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: MARIA N MBEBOH
Title or Position: OWNER
Credential: NP
Phone: 443-410-6131