Healthcare Provider Details

I. General information

NPI: 1104739168
Provider Name (Legal Business Name): BETWEEN TIDES BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 BROAD ST
BOSTON MA
02109-4301
US

IV. Provider business mailing address

56 BROAD ST STE 67310
BOSTON MA
02109-4301
US

V. Phone/Fax

Practice location:
  • Phone: 857-800-0166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KEPEI YI
Title or Position: MANAGER
Credential:
Phone: 857-800-0166