Provider Demographics
NPI:1306652607
Name:REVITALIZE MENTAL HEALTH & INTEGRATIVE MEDICINE LLC
Entity type:Organization
Organization Name:REVITALIZE MENTAL HEALTH & INTEGRATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP
Authorized Official - Phone:734-558-3401
Mailing Address - Street 1:1504 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-4514
Mailing Address - Country:US
Mailing Address - Phone:734-558-3401
Mailing Address - Fax:
Practice Address - Street 1:8225 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-3016
Practice Address - Country:US
Practice Address - Phone:727-242-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty