Provider Demographics
NPI:1376219402
Name:PSYCHE REVIVE LLC
Entity Type:Organization
Organization Name:PSYCHE REVIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-721-5590
Mailing Address - Street 1:30 LA JOLLA CT
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2520
Mailing Address - Country:US
Mailing Address - Phone:347-721-5590
Mailing Address - Fax:
Practice Address - Street 1:4 SWIMMING RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1727
Practice Address - Country:US
Practice Address - Phone:646-708-3846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty