Provider Demographics
NPI:1023762119
Name:HIGH TIDE PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:HIGH TIDE PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:VAN SICKLE-BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:208-557-3870
Mailing Address - Street 1:1500 PANCHERI DR STE 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3212
Mailing Address - Country:US
Mailing Address - Phone:208-557-3870
Mailing Address - Fax:
Practice Address - Street 1:1500 PANCHERI DR STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3212
Practice Address - Country:US
Practice Address - Phone:208-557-3870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty