Healthcare Provider Details

I. General information

NPI: 1902467624
Provider Name (Legal Business Name): LIVE OAK MINDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 BAY BRIDGE DR
GULF BREEZE FL
32561-4468
US

IV. Provider business mailing address

79 BAY BRIDGE DR
GULF BREEZE FL
32561-4468
US

V. Phone/Fax

Practice location:
  • Phone: 850-741-5438
  • Fax:
Mailing address:
  • Phone: 850-741-5438
  • Fax: 850-726-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: HOPE RUIZ
Title or Position: PRESIDENT
Credential:
Phone: 850-741-5438