Provider Demographics
NPI:1518513506
Name:RIVER CITY MENTAL HEALTH COUNSELING, LLC
Entity Type:Organization
Organization Name:RIVER CITY MENTAL HEALTH COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WADE
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-465-1275
Mailing Address - Street 1:308 MARISCO WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32220-4608
Mailing Address - Country:US
Mailing Address - Phone:904-465-1275
Mailing Address - Fax:904-485-8359
Practice Address - Street 1:4711 US HIGHWAY 17 STE 4
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8211
Practice Address - Country:US
Practice Address - Phone:904-465-1275
Practice Address - Fax:904-485-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007650300Medicaid