Provider Demographics
NPI:1467801548
Name:CHANGING TIDES CHILD AND FAMILY ENRICHMENT CENTER
Entity Type:Organization
Organization Name:CHANGING TIDES CHILD AND FAMILY ENRICHMENT CENTER
Other - Org Name:CHANGING TIDES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBER
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-903-7880
Mailing Address - Street 1:2600 DENALI ST STE 606
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2754
Mailing Address - Country:US
Mailing Address - Phone:907-903-7880
Mailing Address - Fax:
Practice Address - Street 1:2600 DENALI ST STE 606
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2754
Practice Address - Country:US
Practice Address - Phone:907-903-7880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK447251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health