Provider Demographics
NPI:1285230185
Name:MIND REVIVE PSYCHIATRY LLC
Entity Type:Organization
Organization Name:MIND REVIVE PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:863-399-2664
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-0640
Mailing Address - Country:US
Mailing Address - Phone:407-561-2500
Mailing Address - Fax:833-410-2620
Practice Address - Street 1:1863 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-5445
Practice Address - Country:US
Practice Address - Phone:407-561-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ280688Medicaid