Healthcare Provider Details

I. General information

NPI: 1346100872
Provider Name (Legal Business Name): TIDES AND LIGHT MENTAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11810 GRAND PARK AVE STE 500
NORTH BETHESDA MD
20852-8679
US

IV. Provider business mailing address

11810 GRAND PARK AVE STE 500
NORTH BETHESDA MD
20852-8679
US

V. Phone/Fax

Practice location:
  • Phone: 410-299-9685
  • Fax:
Mailing address:
  • Phone: 410-299-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CAROLINE ANDERSON
Title or Position: FOUNDER
Credential: CRNP-PMH
Phone: 410-299-9685