Healthcare Provider Details

I. General information

NPI: 1417520891
Provider Name (Legal Business Name): TIDES OF CHANGE THERAPY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HARGETT ST UNIT 234
RALEIGH NC
27601-1596
US

IV. Provider business mailing address

300 W HARGETT ST UNIT 234
RALEIGH NC
27601-1596
US

V. Phone/Fax

Practice location:
  • Phone: 984-788-6570
  • Fax: 844-861-1194
Mailing address:
  • Phone: 984-788-6570
  • Fax: 844-861-1194

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: CARLEIGH DAVIS WEAVER
Title or Position: MEMBER OWNER
Credential: LCSW
Phone: 804-822-5073