Healthcare Provider Details

I. General information

NPI: 1215179056
Provider Name (Legal Business Name): AVANTI WELLNESS CENTER FLLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3574 US 1 S SUITE 113
ST AUGUSTINE FL
32086-6466
US

IV. Provider business mailing address

3574 US 1 S SUITE 113
ST AUGUSTINE FL
32086-6466
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-3115
  • Fax: 904-797-2915
Mailing address:
  • Phone: 904-797-3115
  • Fax: 904-797-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. RANDI B BRAZER
Title or Position: DIRECTOR OF OPERATIONS
Credential: LCSW
Phone: 904-797-3115