MEDICARE: NOURIVIDA WELLNESS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528926144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURIVIDA WELLNESS INC

Provider Business Mailing Address
First Line	:	1222 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5364
Country	:	US
Telephone Number	:	772-361-8448
Fax Number	:	772-492-4478

Provider Business Practice Location Address
First Line	:	1222 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5364
Country	:	US
Telephone Number	:	772-361-8448
Fax Number	:	772-492-4478

Authorized Official
Title or Position	:	CEO
Name	:	YVETTE MCDONALD
Credential	:	LCSW
Telephone Number	:	954-775-4248

Provider Enumeration Date	:	01/13/2026
Last Update Date	:	01/13/2026

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