Healthcare Provider Details

I. General information

NPI: 1811704760
Provider Name (Legal Business Name): ROOTS OF DISCOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 PASEO REYES DR
ST AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

211 TARPON BAY CT
PONTE VEDRA BEACH FL
32081-1501
US

V. Phone/Fax

Practice location:
  • Phone: 904-670-0709
  • Fax:
Mailing address:
  • Phone: 904-710-2092
  • Fax:

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: HEATHER BRINKER
Title or Position: OWNER
Credential: LMHC
Phone: 904-710-2092