MEDICARE: LIVE OAK MINDS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1902467624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVE OAK MINDS LLC

Provider Business Mailing Address
First Line	:	79 BAY BRIDGE DR
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-4468
Country	:	US
Telephone Number	:	850-741-5438
Fax Number	:	850-726-4784

Provider Business Practice Location Address
First Line	:	79 BAY BRIDGE DR
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32561-4468
Country	:	US
Telephone Number	:	850-741-5438
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HOPE RUIZ
Credential	:
Telephone Number	:	850-741-5438

Provider Enumeration Date	:	06/24/2019
Last Update Date	:	06/08/2026

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Directions to “LIVE OAK MINDS LLC ” Practice Location

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