MEDICARE: RIVERTREE COUNSELING ASSOCIATES LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1124742705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERTREE COUNSELING ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	804 E LEAKE ST
Second Line	:
City	:	CLINTON
State	:	MS
Zip	:	39056-4325
Country	:	US
Telephone Number	:	601-670-6444
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 FAIRMONT ST STE B
Second Line	:
City	:	CLINTON
State	:	MS
Zip	:	39056-4739
Country	:	US
Telephone Number	:	601-670-6444
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MRS. LACY LACY DEESE
Credential	:	LPC
Telephone Number	:	601-670-6444

Provider Enumeration Date	:	09/28/2022
Last Update Date	:	09/28/2022

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