Healthcare Provider Details

I. General information

NPI: 1629992540
Provider Name (Legal Business Name): REVIVAMIND BEHAVIORAL HEALTH SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10903 INDIAN HEAD HWY STE 503
FORT WASHINGTON MD
20744
US

IV. Provider business mailing address

8507 OXON HILL RD STE 200
FORT WASHINGTON MD
20744-4774
US

V. Phone/Fax

Practice location:
  • Phone: 227-218-7171
  • Fax:
Mailing address:
  • Phone: 227-218-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: VERONICA BROTHERS
Title or Position: OWNER
Credential: LMSW, PMHNP-BC, CCM
Phone: 227-218-7171