Provider Demographics
NPI:1558958991
Name:TIDAL BALANCED WELLNESS CENTER
Entity Type:Organization
Organization Name:TIDAL BALANCED WELLNESS CENTER
Other - Org Name:TIDAL BALANCED WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:BARELLO
Authorized Official - Last Name:CRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:757-921-7704
Mailing Address - Street 1:325 TACOMA AVE S STE 1
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-2550
Mailing Address - Country:US
Mailing Address - Phone:757-921-7704
Mailing Address - Fax:
Practice Address - Street 1:325 TACOMA AVE S STE 1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-2550
Practice Address - Country:US
Practice Address - Phone:757-921-7704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center