Provider Demographics
NPI:1275939001
Name:TIDEMARK THERAPY PLLC
Entity Type:Organization
Organization Name:TIDEMARK THERAPY PLLC
Other - Org Name:BRITTAINY A. WAGNER, LPC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTAINY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:903-267-4023
Mailing Address - Street 1:1431 W WOODARD ST
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-3449
Mailing Address - Country:US
Mailing Address - Phone:903-267-4023
Mailing Address - Fax:903-487-0600
Practice Address - Street 1:305 W WOODARD ST # 201
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-3136
Practice Address - Country:US
Practice Address - Phone:903-265-8545
Practice Address - Fax:903-487-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty