Provider Demographics
NPI:1023872975
Name:TIDAL BEHAVIORAL ABA NJ LLC
Entity type:Organization
Organization Name:TIDAL BEHAVIORAL ABA NJ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:171-873-6568
Mailing Address - Street 1:7 STERLING PL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-2414
Mailing Address - Country:US
Mailing Address - Phone:171-873-6568
Mailing Address - Fax:
Practice Address - Street 1:820 BEAR TAVERN RD
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-1021
Practice Address - Country:US
Practice Address - Phone:718-736-5689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health