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General NPI Number Information
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NPI Number | 1306652607
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Entity Type | Organization
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Legal Business Name | REVITALIZE MENTAL HEALTH & INTEGRATIVE MEDICINE LLC
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Dates
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Enumeration Date | 12/10/2024
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 8225 STATE ROAD 54
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City | TRINITY
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State | FL
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Zip | 34655-3016
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Country | US
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Telephone | 727-242-8800
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Fax |
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Provider Business Mailing Address
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Address Line | 1504 OHIO AVE
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City | DUNEDIN
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State | FL
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Zip | 34698-4514
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Country | US
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Telephone | 734-558-3401
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHELLE LEE THOMAS
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Credential | APRN, PMHNP
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Telephone | 734-558-3401
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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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