Healthcare Provider Details

I. General information

NPI: 1871999565
Provider Name (Legal Business Name): TIDAL NEUROPSYCHOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2014
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 S HAMPSTEAD VILLAGE DR
HAMPSTEAD NC
28443-3934
US

IV. Provider business mailing address

PO BOX 970
HAMPSTEAD NC
28443-0970
US

V. Phone/Fax

Practice location:
  • Phone: 910-803-1434
  • Fax: 855-672-7002
Mailing address:
  • Phone: 910-803-1434
  • Fax: 855-672-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4633
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4633
License Number StateNC

VIII. Authorized Official

Name: DR. GRIFFIN POLLOCK SUTTON
Title or Position: OWNER, MEMBER
Credential: PH.D.
Phone: 910-803-1434