Healthcare Provider Details

I. General information

NPI: 1437810785
Provider Name (Legal Business Name): TIDALHEALTH SPECIALTY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

IV. Provider business mailing address

P.O. BOX 825461
PHILADELPHIA PA
19182
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7119
  • Fax:
Mailing address:
  • Phone: 410-912-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM PELOT
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 410-543-7497