Healthcare Provider Details

I. General information

NPI: 1427542562
Provider Name (Legal Business Name): TIDAL MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 WASHINGTON ST STE C17
NORWELL MA
02061-1729
US

IV. Provider business mailing address

56 N TRURO ST
HULL MA
02045-3021
US

V. Phone/Fax

Practice location:
  • Phone: 781-952-0153
  • Fax:
Mailing address:
  • Phone: 781-952-0153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberRN2265922
License Number StateMA

VIII. Authorized Official

Name: SARAH SMIGLIANI
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP-BC
Phone: 781-952-0153