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General NPI Number Information
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NPI Number | 1902239270
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Entity Type | Organization
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Legal Business Name | TRACY RILEY COUNSELING LLC
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Dates
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Enumeration Date | 08/09/2013
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Last Update Date | 08/10/2018
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Provider Practice Location Address
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Address Line | 10151 DEERWOOD PARK BLVD STE 200-250
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City | JACKSONVILLE
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State | FL
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Zip | 32256
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Country | US
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Telephone | 904-704-2527
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Fax |
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Provider Business Mailing Address
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Address Line | 10151 DEERWOOD PARK BLVD STE 200-250
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City | JACKSONVILLE
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State | FL
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Zip | 32256-0589
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Country | US
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Telephone | 904-704-2527
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRACY M RILEY
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Credential | LCSW
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Telephone | 904-704-2527
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH 5716
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | ME0045122
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW9355
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License Number State | FL
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