Healthcare Provider Details

I. General information

NPI: 1689470361
Provider Name (Legal Business Name): ERICA OTTO COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 201A
ST AUGUSTINE FL
32080-3119
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 201A
ST AUGUSTINE FL
32080-3119
US

V. Phone/Fax

Practice location:
  • Phone: 904-770-7587
  • Fax: 904-770-7817
Mailing address:
  • Phone: 904-770-7587
  • Fax: 904-770-7817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ERICA OTTO GIVENS
Title or Position: PRESIDENT
Credential: LMHC
Phone: 904-770-7587