Healthcare Provider Details

I. General information

NPI: 1689568404
Provider Name (Legal Business Name): TIDALHEALTH PEDIATRIC DEVELOPMENT AND THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30265 COMMERCE DR UNIT 204
MILLSBORO DE
19966-3595
US

IV. Provider business mailing address

30265 COMMERCE DR UNIT 204
MILLSBORO DE
19966-3595
US

V. Phone/Fax

Practice location:
  • Phone: 443-978-6020
  • Fax:
Mailing address:
  • Phone: 443-978-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JAZMINE MAREE HOLLINS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 704-799-6824