Healthcare Provider Details

I. General information

NPI: 1922832062
Provider Name (Legal Business Name): BRAVE HEARTS WELLLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1857 WELLS RD STE 216
ORANGE PARK FL
32073-2340
US

IV. Provider business mailing address

1857 WELLS RD STE 216
ORANGE PARK FL
32073-2340
US

V. Phone/Fax

Practice location:
  • Phone: 904-523-1287
  • Fax:
Mailing address:
  • Phone: 904-523-1287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENIA N. DAVILA ORTIZ
Title or Position: OWNER/ PRESIDENT
Credential: MHC
Phone: 904-523-1287