Healthcare Provider Details

I. General information

NPI: 1609168384
Provider Name (Legal Business Name): TIDES PSYCHOTHERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 DARLINGTON AVENUE
MAHWAH NJ
07430
US

IV. Provider business mailing address

6 VAIL STREET
NUTLEY NJ
07110
US

V. Phone/Fax

Practice location:
  • Phone: 973-699-6916
  • Fax:
Mailing address:
  • Phone: 973-699-6916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05284000
License Number StateNJ

VIII. Authorized Official

Name: TARA M DUBLANICA
Title or Position: OWNER/ PSYCHOTHERAPIST
Credential: LCSW
Phone: 973-699-6916