Provider Demographics
NPI:1376869321
Name:TIDES OF CHANGE CENTER OF WELLNESS
Entity Type:Organization
Organization Name:TIDES OF CHANGE CENTER OF WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:520-249-7650
Mailing Address - Street 1:1451 E REDROCK DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-8499
Mailing Address - Country:US
Mailing Address - Phone:520-249-7650
Mailing Address - Fax:
Practice Address - Street 1:1451 E REDROCK DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-8499
Practice Address - Country:US
Practice Address - Phone:520-249-7650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW10948251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health