Healthcare Provider Details

I. General information

NPI: 1891396693
Provider Name (Legal Business Name): TIDES CHANGING THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2949 FEDERAL BLVD # 205
DENVER CO
80211-3741
US

IV. Provider business mailing address

2921 W 38TH AVE # 190
DENVER CO
80211-2019
US

V. Phone/Fax

Practice location:
  • Phone: 772-485-6301
  • Fax:
Mailing address:
  • Phone: 772-485-6301
  • 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: SAMANTHA ALEXIS MILLER
Title or Position: PRESIDENT, LCSW
Credential: LCSW
Phone: 772-485-6301