Provider Demographics
NPI:1053981852
Name:RIVER'S EDGE COUNSELING, PLLC
Entity type:Organization
Organization Name:RIVER'S EDGE COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-379-8675
Mailing Address - Street 1:43 KNIGHT BOXX RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7395
Mailing Address - Country:US
Mailing Address - Phone:904-379-8675
Mailing Address - Fax:904-423-0490
Practice Address - Street 1:8465 MERCHANTS WAY STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222-2858
Practice Address - Country:US
Practice Address - Phone:904-379-8675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERS EDGE COUNSELING PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020394200Medicaid