MEDICARE: RIVER'S EDGE COUNSELING, PLLC

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	1041C0700X	Clinical Social Worker
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1548958168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER'S EDGE COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	43 KNIGHT BOXX RD STE 1
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7395
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3003 CLAIRE LN STE 202
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-6665
Country	:	US
Telephone Number	:	904-379-8675
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA HANNAH
Credential	:
Telephone Number	:	904-379-8675

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	05/01/2023

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