Healthcare Provider Details

I. General information

NPI: 1447125869
Provider Name (Legal Business Name): BRANCH LANE PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 FORT WADE RD STE 100
PONTE VEDRA BEACH FL
32081-5114
US

IV. Provider business mailing address

90 FORT WADE RD STE 100
PONTE VEDRA BEACH FL
32081-5114
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-9851
  • Fax:
Mailing address:
  • Phone: 347-377-0973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ERICA OPPENHEIMER
Title or Position: MANAGER
Credential: LCSW
Phone: 347-377-0973