Healthcare Provider Details

I. General information

NPI: 1245823160
Provider Name (Legal Business Name): TIDES WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 UNION AVE STE 10
BRIELLE NJ
08730-1838
US

IV. Provider business mailing address

617 UNION AVE STE 10
BRIELLE NJ
08730-1838
US

V. Phone/Fax

Practice location:
  • Phone: 973-464-6985
  • Fax:
Mailing address:
  • Phone: 973-464-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROLYN ARTALE
Title or Position: CEO
Credential: LCSW
Phone: 973-464-6985