Provider Demographics
NPI:1114513967
Name:LIFE TIDE THERAPY, LLC
Entity Type:Organization
Organization Name:LIFE TIDE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSW
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:857-302-4902
Mailing Address - Street 1:54 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3377
Mailing Address - Country:US
Mailing Address - Phone:603-520-6388
Mailing Address - Fax:
Practice Address - Street 1:54 HIGH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3377
Practice Address - Country:US
Practice Address - Phone:603-520-6388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty