Healthcare Provider Details

I. General information

NPI: 1922844174
Provider Name (Legal Business Name): WINGS OF HOPE THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 N 10TH ST STE A2
ST AUGUSTINE FL
32084-1872
US

IV. Provider business mailing address

2825 N 10TH ST STE A2
ST AUGUSTINE FL
32084-1872
US

V. Phone/Fax

Practice location:
  • Phone: 904-994-0903
  • Fax:
Mailing address:
  • Phone: 904-994-0903
  • 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: CAROLYN MOLDOVANYI
Title or Position: OWNER
Credential: LMHC
Phone: 904-994-0903