Provider Demographics
NPI:1659986685
Name:NEW TIDE PSYCHOTHERAPY
Entity Type:Organization
Organization Name:NEW TIDE PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:540-538-5790
Mailing Address - Street 1:1425 LONG GROVE DR UNIT 304
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8422
Mailing Address - Country:US
Mailing Address - Phone:540-538-5790
Mailing Address - Fax:
Practice Address - Street 1:753 JOHNNIE DODDS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3054
Practice Address - Country:US
Practice Address - Phone:540-538-5790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty