Provider Demographics
NPI:1639887672
Name:CHANGING TIDES COUNSELING, LLC
Entity Type:Organization
Organization Name:CHANGING TIDES COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROSHIUS-CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:813-461-5370
Mailing Address - Street 1:51 S MAIN AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-3937
Mailing Address - Country:US
Mailing Address - Phone:920-370-7680
Mailing Address - Fax:
Practice Address - Street 1:51 S MAIN AVE STE 304
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3937
Practice Address - Country:US
Practice Address - Phone:920-370-7680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21772400Medicaid