Healthcare Provider Details

I. General information

NPI: 1164051025
Provider Name (Legal Business Name): TIDEMARK BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 DELMAR AVE
WEST CHESTER PA
19380-4027
US

IV. Provider business mailing address

13 RYAN FROST WAY
ESSEX MD
21221-1646
US

V. Phone/Fax

Practice location:
  • Phone: 484-432-7882
  • Fax:
Mailing address:
  • Phone: 484-432-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RYNE LAXTON
Title or Position: CEO
Credential: LCSW-C
Phone: 484-432-7882