Provider Demographics
NPI:1336987551
Name:RENOVATE MENTAL, LLC
Entity type:Organization
Organization Name:RENOVATE MENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:301-828-2350
Mailing Address - Street 1:12410 MILESTONE CENTER DR STE 600
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-7102
Mailing Address - Country:US
Mailing Address - Phone:301-828-2350
Mailing Address - Fax:301-828-2350
Practice Address - Street 1:12410 MILESTONE CENTER DR STE 600
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-7102
Practice Address - Country:US
Practice Address - Phone:301-828-2350
Practice Address - Fax:301-828-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty