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General NPI Number Information
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NPI Number | 1518792365
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Entity Type | Organization
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Legal Business Name | MINDSET & RECOVERY DIVERSIFIED LLC
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Dates
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Enumeration Date | 09/03/2024
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 6633 WOODS ISLAND CIR APT 206
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-1475
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Country | US
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Telephone | 772-208-8734
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Fax | 772-667-5186
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Provider Business Mailing Address
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Address Line | 11582 SW VILLAGE PKWY # 1262
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City | PORT ST LUCIE
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State | FL
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Zip | 34987-2392
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Country | US
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Telephone | 772-208-8734
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Fax |
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Authorized Official
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Title or Position | PMHNP-BC
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Name | KHATRIENA D JOHNSON
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Credential | APRN
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Telephone | 772-208-8734
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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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