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General NPI Number Information
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NPI Number | 1215179056
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Entity Type | Organization
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Legal Business Name | AVANTI WELLNESS CENTER FLLLP
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Dates
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Enumeration Date | 03/25/2009
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Last Update Date | 05/19/2011
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Provider Practice Location Address
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Address Line | 3574 US 1 S SUITE 113
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6466
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Country | US
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Telephone | 904-797-3115
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Fax | 904-797-2915
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Provider Business Mailing Address
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Address Line | 3574 US 1 S SUITE 113
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6466
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Country | US
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Telephone | 904-797-3115
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Fax | 904-797-2915
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MRS. RANDI B BRAZER
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Credential | LCSW
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Telephone | 904-797-3115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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