Healthcare Provider Details

I. General information

NPI: 1053701425
Provider Name (Legal Business Name): CHANGING TIDES TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 SPERRY AVE SUITE 3
VENTURA CA
93003-7408
US

IV. Provider business mailing address

5301 SEABREEZE WAY
OXNARD CA
93035-1048
US

V. Phone/Fax

Practice location:
  • Phone: 844-883-3869
  • Fax:
Mailing address:
  • Phone: 844-883-3869
  • Fax: 805-624-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BERKELEY BEAUDEAN DAINS
Title or Position: CEO
Credential: CATC, CIP,BS
Phone: 805-506-1541