Healthcare Provider Details

I. General information

NPI: 1376869321
Provider Name (Legal Business Name): TIDES OF CHANGE CENTER OF WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 E REDROCK DR
SIERRA VISTA AZ
85650-8499
US

IV. Provider business mailing address

1451 E REDROCK DR
SIERRA VISTA AZ
85650-8499
US

V. Phone/Fax

Practice location:
  • Phone: 520-249-7650
  • Fax:
Mailing address:
  • Phone: 520-249-7650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLCSW10948
License Number StateAZ

VIII. Authorized Official

Name: MARIANNE S VALLADARES
Title or Position: PRESIDENT
Credential: LCSW
Phone: 520-249-7650