Healthcare Provider Details

I. General information

NPI: 1295325298
Provider Name (Legal Business Name): HAROLD TIDAY TCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 TROPICANA ST
MIRAMAR FL
33023-2434
US

IV. Provider business mailing address

7840 TROPICANA ST
MIRAMAR FL
33023-2434
US

V. Phone/Fax

Practice location:
  • Phone: 786-818-4947
  • Fax:
Mailing address:
  • Phone: 786-818-4947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCM103358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: