Healthcare Provider Details

I. General information

NPI: 1811751415
Provider Name (Legal Business Name): TIDAL ABA NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 BEAR TAVERN RD
EWING NJ
08628-1021
US

IV. Provider business mailing address

600 BAYVIEW AVE STE 400
INWOOD NY
11096-1606
US

V. Phone/Fax

Practice location:
  • Phone: 718-736-5689
  • Fax:
Mailing address:
  • Phone: 718-675-6957
  • 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 BRAVMANN
Title or Position: CONTROLLER
Credential:
Phone: 718-675-6957