Healthcare Provider Details

I. General information

NPI: 1124742705
Provider Name (Legal Business Name): RIVERTREE COUNSELING ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 FAIRMONT ST STE B
CLINTON MS
39056-4739
US

IV. Provider business mailing address

804 E LEAKE ST
CLINTON MS
39056-4325
US

V. Phone/Fax

Practice location:
  • Phone: 601-670-6444
  • Fax:
Mailing address:
  • Phone: 601-670-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LACY LACY DEESE
Title or Position: OWNER/MANAGER
Credential: LPC
Phone: 601-670-6444