Provider Demographics
NPI:1578224929
Name:TIDALHEALTH SPECIALTY CARE, LLC
Entity Type:Organization
Organization Name:TIDALHEALTH SPECIALTY CARE, LLC
Other - Org Name:TIDALHEALTH BEHAVIORAL HEALTH OCEAN PINES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-912-6059
Mailing Address - Street 1:P.O. BOX 825461
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182
Mailing Address - Country:US
Mailing Address - Phone:410-912-6989
Mailing Address - Fax:
Practice Address - Street 1:11101 CATHAGE RD
Practice Address - Street 2:UNIT 102
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-2115
Practice Address - Country:US
Practice Address - Phone:410-912-6104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health