Healthcare Provider Details

I. General information

NPI: 1073481719
Provider Name (Legal Business Name): TIDAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 N EMERALD CT
MAIZE KS
67101-8717
US

IV. Provider business mailing address

5005 N EMERALD CT
MAIZE KS
67101-8717
US

V. Phone/Fax

Practice location:
  • Phone: 316-308-5426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELSEY BALL
Title or Position: OWNER
Credential: LCPC
Phone: 316-308-5426