Healthcare Provider Details

I. General information

NPI: 1699135186
Provider Name (Legal Business Name): EBB TIDE TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5737 CORPORATE WAY
WEST PALM BEACH FL
33407-2003
US

IV. Provider business mailing address

5737 CORPORATE WAY
WEST PALM BEACH FL
33407-2003
US

V. Phone/Fax

Practice location:
  • Phone: 561-508-8330
  • Fax:
Mailing address:
  • Phone: 561-508-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH KILKENNY DONOVAN
Title or Position: CEO
Credential:
Phone: 561-508-8330