Healthcare Provider Details

I. General information

NPI: 1255728614
Provider Name (Legal Business Name): TIDAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 MAIN ST SUITE 304
OLD SAYBROOK CT
06475-2326
US

IV. Provider business mailing address

263 MAIN ST SUITE 304
OLD SAYBROOK CT
06475-2326
US

V. Phone/Fax

Practice location:
  • Phone: 860-876-7488
  • Fax:
Mailing address:
  • Phone: 860-876-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001498
License Number StateCT

VIII. Authorized Official

Name: MRS. EMILY GREENE REYNOLDS
Title or Position: OWNER / PSYCHOTHERAPIST
Credential: LPC
Phone: 860-876-7488