Provider Demographics
NPI:1497483689
Name:IVY BRIDGE COUNSELING, INC.
Entity Type:Organization
Organization Name:IVY BRIDGE COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:912-572-1602
Mailing Address - Street 1:2272 WEKIVA VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-2511
Mailing Address - Country:US
Mailing Address - Phone:912-572-1602
Mailing Address - Fax:540-566-5036
Practice Address - Street 1:587 E SR 434 UNIT 1021B
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5284
Practice Address - Country:US
Practice Address - Phone:407-565-7942
Practice Address - Fax:540-566-5036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017481030001Medicaid