Healthcare Provider Details

I. General information

NPI: 1699145854
Provider Name (Legal Business Name): MENTAL EDGE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1198 S GOVERNORS AVE STE 201
DOVER DE
19904-6930
US

IV. Provider business mailing address

1198 S GOVERNORS AVE STE 201
DOVER DE
19904-6930
US

V. Phone/Fax

Practice location:
  • Phone: 302-382-8698
  • Fax: 302-269-3800
Mailing address:
  • Phone: 302-382-8698
  • Fax: 302-269-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN VANDER VEN JR.
Title or Position: PRESIDENT
Credential: L.P.C.M.H.
Phone: 302-382-8698