Provider Demographics
NPI:1649076191
Name:DEEP TIDES THERAPY PLLC
Entity type:Organization
Organization Name:DEEP TIDES THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:CORINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-754-2817
Mailing Address - Street 1:14205 N MO PAC EXPY STE 570
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1804 E 18TH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7322
Practice Address - Country:US
Practice Address - Phone:503-754-2817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty