MEDICARE: SHARDAE TRIPP COUNSELING, LLC

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134809239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHARDAE TRIPP COUNSELING, LLC

Provider Business Mailing Address
First Line	:	5590 NW PINE TRAIL CIR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-5349
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5590 NW PINE TRAIL CIR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-5349
Country	:	US
Telephone Number	:	772-418-7797
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SHARDAE TRIPP
Credential	:
Telephone Number	:	772-418-7797

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	07/24/2023

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