Provider Demographics
NPI:1922832062
Name:BRAVE HEARTS WELLLNESS CENTER INC
Entity type:Organization
Organization Name:BRAVE HEARTS WELLLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAVILA ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MHC
Authorized Official - Phone:904-523-1287
Mailing Address - Street 1:1857 WELLS RD STE 216
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2340
Mailing Address - Country:US
Mailing Address - Phone:904-523-1287
Mailing Address - Fax:
Practice Address - Street 1:1857 WELLS RD STE 216
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2340
Practice Address - Country:US
Practice Address - Phone:904-523-1287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty