Healthcare Provider Details

I. General information

NPI: 1720595242
Provider Name (Legal Business Name): TIDEMARK INTERVENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7822 EASTERN AVE
BALTIMORE MD
21224-2115
US

IV. Provider business mailing address

7822 EASTERN AVE
BALTIMORE MD
21224-2115
US

V. Phone/Fax

Practice location:
  • Phone: 443-596-8178
  • Fax:
Mailing address:
  • Phone: 443-596-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18885
License Number StateMD

VIII. Authorized Official

Name: RYNE LAXTON
Title or Position: CEO
Credential: LCSW-C
Phone: 484-432-7882