Provider Demographics
NPI:1417520891
Name:TIDES OF CHANGE THERAPY SERVICES PLLC
Entity Type:Organization
Organization Name:TIDES OF CHANGE THERAPY SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLEIGH
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-822-5073
Mailing Address - Street 1:300 W HARGETT ST UNIT 234
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1596
Mailing Address - Country:US
Mailing Address - Phone:984-788-6570
Mailing Address - Fax:844-861-1194
Practice Address - Street 1:300 W HARGETT ST UNIT 234
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1596
Practice Address - Country:US
Practice Address - Phone:984-788-6570
Practice Address - Fax:844-861-1194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336293000Medicaid