Healthcare Provider Details

I. General information

NPI: 1093351629
Provider Name (Legal Business Name): TIDAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 NORTHBANK PKWY SUITE 248
TUSCALOOSA AL
35406-2439
US

IV. Provider business mailing address

1490 NORTHBANK PKWY SUITE 248
TUSCALOOSA AL
35406-2439
US

V. Phone/Fax

Practice location:
  • Phone: 205-722-7227
  • Fax:
Mailing address:
  • Phone: 205-722-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MOLLIE OLINE PUTYRAE
Title or Position: MENTAL HEALTH COUNSELING
Credential: MA
Phone: 509-981-3104