Provider Demographics
NPI:1669856514
Name:REVIVING MINDS LLC
Entity Type:Organization
Organization Name:REVIVING MINDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIKES BICKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:985-893-0693
Mailing Address - Street 1:70380 HIGHWAY 21 STE 2
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8128
Mailing Address - Country:US
Mailing Address - Phone:985-893-0693
Mailing Address - Fax:985-790-7090
Practice Address - Street 1:112 INNWOOD DR STE H
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-9134
Practice Address - Country:US
Practice Address - Phone:985-893-0693
Practice Address - Fax:985-790-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08162363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty