MEDICARE: RIVER'S EDGE COUNSELING, PLLC

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	12220	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396155768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER'S EDGE COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	43 KNIGHT BOXX RD
Second Line	:	STE 1
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7395
Country	:	US
Telephone Number	:	904-379-8675
Fax Number	:	904-423-0490

Provider Business Practice Location Address
First Line	:	43 KNIGHT BOXX RD
Second Line	:	STE 1
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7395
Country	:	US
Telephone Number	:	904-379-8675
Fax Number	:	904-423-0490

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA HANNAH
Credential	:	LMHC
Telephone Number	:	904-379-8675

Provider Enumeration Date	:	05/06/2014
Last Update Date	:	01/12/2017

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