Provider Demographics
NPI:1720353741
Name:EBB TIDE THERAPY
Entity Type:Organization
Organization Name:EBB TIDE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:GAE
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC, CTS
Authorized Official - Phone:414-372-7212
Mailing Address - Street 1:2821 N 4TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2367
Mailing Address - Country:US
Mailing Address - Phone:414-372-7212
Mailing Address - Fax:414-372-7213
Practice Address - Street 1:2821 N 4TH ST STE 209
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2367
Practice Address - Country:US
Practice Address - Phone:414-372-7212
Practice Address - Fax:414-372-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-09
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1971-132101YA0400X
WI7197-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366529182Medicaid