Provider Demographics
NPI:1164051025
Name:TIDEMARK BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:TIDEMARK BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:484-432-7882
Mailing Address - Street 1:13 RYAN FROST WAY
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-1646
Mailing Address - Country:US
Mailing Address - Phone:484-432-7882
Mailing Address - Fax:
Practice Address - Street 1:1272 DELMAR AVE
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4027
Practice Address - Country:US
Practice Address - Phone:484-432-7882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty