Provider Demographics
NPI:1316205354
Name:LIFE TIDE COUNSELING PC
Entity Type:Organization
Organization Name:LIFE TIDE COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:910-326-8881
Mailing Address - Street 1:PO BOX 1216
Mailing Address - Street 2:
Mailing Address - City:SWANSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28584-1216
Mailing Address - Country:US
Mailing Address - Phone:910-326-8881
Mailing Address - Fax:910-326-2342
Practice Address - Street 1:205 WARD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SWANSBORO
Practice Address - State:NC
Practice Address - Zip Code:28584-8259
Practice Address - Country:US
Practice Address - Phone:910-326-8881
Practice Address - Fax:910-326-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105190Medicaid