Healthcare Provider Details

I. General information

NPI: 1497483689
Provider Name (Legal Business Name): IVY BRIDGE COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 01/31/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 E SR 434 UNIT 1021B
LONGWOOD FL
32750-5284
US

IV. Provider business mailing address

2272 WEKIVA VILLAGE LN
APOPKA FL
32703-2511
US

V. Phone/Fax

Practice location:
  • Phone: 407-565-7942
  • Fax: 540-566-5036
Mailing address:
  • Phone: 912-572-1602
  • Fax: 540-566-5036

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: RENATA HUEWITT
Title or Position: OWNER, MENTAL HEALTH THERAPIST
Credential: LPC
Phone: 912-572-1602