Provider Demographics
NPI:1346933561
Name:TIDAL INTEGRATED HEALTH, INC
Entity Type:Organization
Organization Name:TIDAL INTEGRATED HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAYZANDRA
Authorized Official - Middle Name:LEIGH EXUM
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-493-6788
Mailing Address - Street 1:2307 NORWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-1601
Mailing Address - Country:US
Mailing Address - Phone:252-493-6788
Mailing Address - Fax:
Practice Address - Street 1:1025 DIRECTOR CT STE E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5996
Practice Address - Country:US
Practice Address - Phone:252-493-6525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-01
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)