MEDICARE: VIBRANT INTEGRATIVE PSYCHIATRY PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1962116459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRANT INTEGRATIVE PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	6530 SHERIDAN RD STE 3
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5063
Country	:	US
Telephone Number	:	224-285-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	6530 SHERIDAN RD STE 3
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5063
Country	:	US
Telephone Number	:	224-285-6006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ILYA MELINA RAY
Credential	:	APNP
Telephone Number	:	224-285-6006

Provider Enumeration Date	:	01/09/2023
Last Update Date	:	04/10/2023

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