Healthcare Provider Details

I. General information

NPI: 1245809912
Provider Name (Legal Business Name): MENTAL WEALTH TRIBE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 11/24/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WEBB DR STE 212
DAVENPORT FL
33837-3904
US

IV. Provider business mailing address

121 WEBB DR STE 212
DAVENPORT FL
33837-3904
US

V. Phone/Fax

Practice location:
  • Phone: 863-866-0909
  • Fax:
Mailing address:
  • Phone: 863-866-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. YASMINE DOMINIQUE-MERVEUS
Title or Position: OWNER
Credential: MSW
Phone: 863-866-0909