Healthcare Provider Details

I. General information

NPI: 1508578717
Provider Name (Legal Business Name): TIDES OF CHANGE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 APPLE ST
TINTON FALLS NJ
07724-2636
US

IV. Provider business mailing address

PO BOX 8502
RED BANK NJ
07701-8502
US

V. Phone/Fax

Practice location:
  • Phone: 603-361-6402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: KRISTINE LANE
Title or Position: OWNER
Credential:
Phone: 603-361-6402