Healthcare Provider Details

I. General information

NPI: 1174401236
Provider Name (Legal Business Name): TIDE AND SHORE MARRIAGE AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 PENNSFIELD PL STE 208
THOUSAND OAKS CA
91360-5530
US

IV. Provider business mailing address

2075 HIETTER AVE
SIMI VALLEY CA
93063-2851
US

V. Phone/Fax

Practice location:
  • Phone: 805-694-0251
  • Fax:
Mailing address:
  • Phone: 805-694-0251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KAIDI LIU
Title or Position: OWNER
Credential:
Phone: 818-606-9079