Healthcare Provider Details

I. General information

NPI: 1891505848
Provider Name (Legal Business Name): TIDES OF TOTALITY THERAPEUTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CENTRAL AVE STE 250
NORTHFIELD IL
60093-3024
US

IV. Provider business mailing address

1656 WARRINGTON LN
CRYSTAL LAKE IL
60014-2020
US

V. Phone/Fax

Practice location:
  • Phone: 815-505-0110
  • Fax:
Mailing address:
  • Phone:
  • 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: KRISTEN WIDING
Title or Position: CEO
Credential: LCSW
Phone: 815-505-0110