Healthcare Provider Details

I. General information

NPI: 1023872975
Provider Name (Legal Business Name): TIDAL BEHAVIORAL ABA NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 BEAR TAVERN RD
EWING NJ
08628-1021
US

IV. Provider business mailing address

7 STERLING PL
LAWRENCE NY
11559-2414
US

V. Phone/Fax

Practice location:
  • Phone: 718-736-5689
  • Fax:
Mailing address:
  • Phone: 171-873-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JACK ELIAS
Title or Position: CONTROLLER
Credential:
Phone: 171-873-6568