Healthcare Provider Details

I. General information

NPI: 1174362974
Provider Name (Legal Business Name): REVOLVE WELLNESS HUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WINTERSON RD STE 200
LINTHICUM MD
21090-2245
US

IV. Provider business mailing address

1190 WINTERSON RD STE 200
LINTHICUM MD
21090-2245
US

V. Phone/Fax

Practice location:
  • Phone: 443-201-6063
  • Fax:
Mailing address:
  • Phone: 443-318-3289
  • Fax: 443-788-1787

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
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: UZOAMAKA MBADUGHA
Title or Position: CRNP-PMH
Credential:
Phone: 443-201-6063