Provider Demographics
NPI:1811273568
Name:TIDES OF CHANGE
Entity type:Organization
Organization Name:TIDES OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:VALLADARES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:520-458-2250
Mailing Address - Street 1:333 W WILCOX DR
Mailing Address - Street 2:STE. 303
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1789
Mailing Address - Country:US
Mailing Address - Phone:520-458-2250
Mailing Address - Fax:520-458-2269
Practice Address - Street 1:333 W WILCOX DR
Practice Address - Street 2:STE. 303
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-1789
Practice Address - Country:US
Practice Address - Phone:520-458-2250
Practice Address - Fax:520-458-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC12687101Y00000X
AZLISAC10504101YA0400X
AZLMSW1041C0700X
AZLCSW123941041C0700X
LCSW29221041C0700X
AZLCSW28111041C0700X
AZLCSW109481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty