Healthcare Provider Details

I. General information

NPI: 1659000313
Provider Name (Legal Business Name): OLIVE TREE MATERNAL WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6076
US

IV. Provider business mailing address

2465 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6076
US

V. Phone/Fax

Practice location:
  • Phone: 770-896-2659
  • Fax:
Mailing address:
  • Phone: 770-896-2659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICOLE MATEO
Title or Position: OWNER
Credential: LPC, LMHC
Phone: 770-896-2659