MEDICARE: SPRUCE CREEK COUNSELING

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942014055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRUCE CREEK COUNSELING

Provider Business Mailing Address
First Line	:	6069 SPRUCE POINT CIR
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-5508
Country	:	US
Telephone Number	:	240-818-9499
Fax Number	:

Provider Business Practice Location Address
First Line	:	6069 SPRUCE POINT CIR
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-5508
Country	:	US
Telephone Number	:	240-818-9499
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	SHANNON MARIE KING
Credential	:
Telephone Number	:	240-818-9499

Provider Enumeration Date	:	02/07/2025
Last Update Date	:	02/07/2025

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