Healthcare Provider Details

I. General information

NPI: 1316788326
Provider Name (Legal Business Name): TIDAL FALLS COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/12/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 STATE STREET STE 5
BANGOR ME
04401-3460
US

IV. Provider business mailing address

499 BROADWAY # 238
BANGOR ME
04401-3460
US

V. Phone/Fax

Practice location:
  • Phone: 207-745-2828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN BIGNEY
Title or Position: OWNER
Credential: LCSW
Phone: 207-745-2828