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General NPI Number Information
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NPI Number | 1285230185
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Entity Type | Organization
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Legal Business Name | MIND REVIVE PSYCHIATRY LLC
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Dates
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Enumeration Date | 12/07/2020
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 1863 SKYVIEW DR
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City | AUBURNDALE
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State | FL
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Zip | 33823-5445
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Country | US
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Telephone | 407-561-2500
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 640
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City | AUBURNDALE
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State | FL
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Zip | 33823-0640
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Country | US
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Telephone | 407-561-2500
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Fax | 833-410-2620
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Authorized Official
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Title or Position | PSYCHIATRIC NURSE PRACTITIONER
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Name | MR. MARCUS L ROBINSON
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Credential | PMHNP-BC
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Telephone | 863-399-2664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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