Healthcare Provider Details

I. General information

NPI: 1730007782
Provider Name (Legal Business Name): RISING TIDE LICENSED CLINICAL SOCIAL WORKER A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 MORNING SUN AVE
MILL VALLEY CA
94941-3503
US

IV. Provider business mailing address

249 MORNING SUN AVE
MILL VALLEY CA
94941-3503
US

V. Phone/Fax

Practice location:
  • Phone: 309-868-3809
  • Fax:
Mailing address:
  • Phone: 309-868-3809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LUCAS MICHAEL GARRISON
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 309-868-3809