MEDICARE: PSYCHIATRIC BEHAVIORAL WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1629933924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHIATRIC BEHAVIORAL WELLNESS

Provider Business Mailing Address
First Line	:	3556 DARTMOUTH LN
Second Line	:
City	:	ROWLAND HGHTS
State	:	CA
Zip	:	91748-5136
Country	:	US
Telephone Number	:	562-304-5150
Fax Number	:	565-623-1710

Provider Business Practice Location Address
First Line	:	3556 DARTMOUTH LN
Second Line	:
City	:	ROWLAND HGHTS
State	:	CA
Zip	:	91748-5136
Country	:	US
Telephone Number	:	562-304-5150
Fax Number	:	565-623-1710

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	MR. REVMAX TECHNOLOGIES
Credential	:
Telephone Number	:	720-784-9413

Provider Enumeration Date	:	12/18/2025
Last Update Date	:	12/18/2025

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