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General NPI Number Information
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NPI Number | 1043182280
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Entity Type | Organization
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Legal Business Name | MIND REVIVAL PSYCH INC
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Dates
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Enumeration Date | 09/18/2025
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Last Update Date | 12/12/2025
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Provider Practice Location Address
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Address Line | 7201 S STONY ISLAND AVE # 7
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City | CHICAGO
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State | IL
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Zip | 60649-2806
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Country | US
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Telephone | 773-690-5300
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Fax | 870-201-4835
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Provider Business Mailing Address
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Address Line | 7201 S STONY ISLAND AVE # 7
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City | CHICAGO
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State | IL
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Zip | 60649-2806
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Country | US
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Telephone | 773-690-5300
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Fax | 870-201-4835
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Authorized Official
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Title or Position | NP/OWNER
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Name | MRS. EBONIE WILLIAMS
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Credential | NP
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Telephone | 708-715-2035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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