Healthcare Provider Details

I. General information

NPI: 1629768775
Provider Name (Legal Business Name): TIDA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 MONTAUK DR
CROFTON MD
21114-3245
US

IV. Provider business mailing address

2209 MONTAUK DR
CROFTON MD
21114-3245
US

V. Phone/Fax

Practice location:
  • Phone: 240-305-7446
  • Fax:
Mailing address:
  • Phone: 240-305-7446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: IDA MABELLE KONCHOU
Title or Position: PMHNP
Credential:
Phone: 240-305-7446