Provider Demographics
NPI:1962027094
Name:TIDALHEALTH SPECIALTY CARE, LLC
Entity Type:Organization
Organization Name:TIDALHEALTH SPECIALTY CARE, LLC
Other - Org Name:TIDALHEALTH BEHAVIORAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-912-6059
Mailing Address - Street 1:PO BOX 2498
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-2498
Mailing Address - Country:US
Mailing Address - Phone:410-912-4976
Mailing Address - Fax:
Practice Address - Street 1:200 E VINE ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5531
Practice Address - Country:US
Practice Address - Phone:410-543-7119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDALHEALTH SPECIALTY CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-15
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