Healthcare Provider Details

I. General information

NPI: 1912473265
Provider Name (Legal Business Name): TIDALHEALTH PENINSULA REGIONAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 01/11/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E. VINE STREET TIDALHEALTH CRISIS CENTER
SALISBURY MD
21804-2180
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7181
  • Fax: 410-912-4972
Mailing address:
  • Phone: 410-912-6989
  • Fax: 410-912-4972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICKEY GRIFFIN
Title or Position: SENIOR DIRECTOR
Credential: MBA, CRCE, CPC
Phone: 410-543-7437