Healthcare Provider Details

I. General information

NPI: 1013827245
Provider Name (Legal Business Name): MIND REVITALIZED PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 UNITY AVE N STE 307B
BROOKLYN PARK MN
55443-3136
US

IV. Provider business mailing address

7420 UNITY AVE N STE 307B
BROOKLYN PARK MN
55443-3136
US

V. Phone/Fax

Practice location:
  • Phone: 609-338-4325
  • Fax:
Mailing address:
  • Phone: 609-338-4325
  • Fax:

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: ABENA V PREMPEH
Title or Position: MEMBER-MANAGER
Credential: DNP, PMHNP-BC
Phone: 609-338-4325