Provider Demographics
NPI:1912473265
Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type:Organization
Organization Name:TIDALHEALTH PENINSULA REGIONAL, INC.
Other - Org Name:TIDALHEALTH CRISIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CRCE, CPC
Authorized Official - Phone:410-543-7437
Mailing Address - Street 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-912-6989
Mailing Address - Fax:410-912-4972
Practice Address - Street 1:200 E. VINE STREET
Practice Address - Street 2:TIDALHEALTH CRISIS CENTER
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-2180
Practice Address - Country:US
Practice Address - Phone:410-543-7181
Practice Address - Fax:410-912-4972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health