Provider Demographics
NPI:1134995426
Name:REVITALIZE PSYCHIATRIC SERVICES II, INC.
Entity type:Organization
Organization Name:REVITALIZE PSYCHIATRIC SERVICES II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HUFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP, PMHNP-BC
Authorized Official - Phone:815-212-1478
Mailing Address - Street 1:11919 CASTINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-1807
Mailing Address - Country:US
Mailing Address - Phone:815-212-1478
Mailing Address - Fax:
Practice Address - Street 1:27524 CASHFORD CIR STE 102
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6947
Practice Address - Country:US
Practice Address - Phone:815-212-1478
Practice Address - Fax:813-906-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty