Healthcare Provider Details

I. General information

NPI: 1396664595
Provider Name (Legal Business Name): MATRESCENCE METHOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 CABEZA ST
SAINT AUGUSTINE FL
32080-4524
US

IV. Provider business mailing address

205 CABEZA ST
SAINT AUGUSTINE FL
32080-4524
US

V. Phone/Fax

Practice location:
  • Phone: 479-372-2995
  • Fax:
Mailing address:
  • Phone: 479-372-2995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR LEE-WAMBOLT
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTD, OTR/L
Phone: 479-372-2995