Provider Demographics
NPI:1760226930
Name:RESTORATION PSYCHIATRY PLLC
Entity type:Organization
Organization Name:RESTORATION PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AKINBOWALE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYENI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:651-734-5884
Mailing Address - Street 1:4548 BAILEY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5508
Mailing Address - Country:US
Mailing Address - Phone:651-734-5884
Mailing Address - Fax:
Practice Address - Street 1:2042 WOODDALE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2981
Practice Address - Country:US
Practice Address - Phone:651-758-1899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)