Provider Demographics
NPI:1003198409
Name:RIVERSIDE COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:RIVERSIDE COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:THEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CAP
Authorized Official - Phone:321-421-6992
Mailing Address - Street 1:1301 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5390
Mailing Address - Country:US
Mailing Address - Phone:321-421-6992
Mailing Address - Fax:321-421-6993
Practice Address - Street 1:1301 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5390
Practice Address - Country:US
Practice Address - Phone:321-421-6992
Practice Address - Fax:321-421-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW91341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGF444AMedicare UPIN