Provider Demographics
NPI:1275645939
Name:TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES
Other - Org Name:TIDESIDE
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEATTIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-669-6011
Mailing Address - Street 1:94 MILL ST
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-4040
Mailing Address - Country:US
Mailing Address - Phone:207-866-2636
Mailing Address - Fax:207-669-6011
Practice Address - Street 1:64 CHURCH ST
Practice Address - Street 2:TIDESIDE
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1658
Practice Address - Country:US
Practice Address - Phone:207-669-6011
Practice Address - Fax:207-669-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1018103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty