Provider Demographics
NPI:1518792365
Name:MINDSET & RECOVERY DIVERSIFIED LLC
Entity type:Organization
Organization Name:MINDSET & RECOVERY DIVERSIFIED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:KHATRIENA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:772-208-8734
Mailing Address - Street 1:11582 SW VILLAGE PKWY # 1262
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2392
Mailing Address - Country:US
Mailing Address - Phone:772-208-8734
Mailing Address - Fax:
Practice Address - Street 1:6633 WOODS ISLAND CIR APT 206
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1475
Practice Address - Country:US
Practice Address - Phone:772-208-8734
Practice Address - Fax:772-667-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty