Healthcare Provider Details

I. General information

NPI: 1629914940
Provider Name (Legal Business Name): MARY ELIZABETH HEROLD VON MOHR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5344 ALLEN PL
AVE MARIA FL
34142-5073
US

IV. Provider business mailing address

5344 ALLEN PL
AVE MARIA FL
34142-5073
US

V. Phone/Fax

Practice location:
  • Phone: 904-304-7117
  • Fax:
Mailing address:
  • Phone: 904-304-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19996
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: