Healthcare Provider Details

I. General information

NPI: 1700849148
Provider Name (Legal Business Name): The Changing Tide Body, Mind & Spirit P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 Main Street Ste A
mathews VA
23109-0327
US

IV. Provider business mailing address

75 main street ste a
mathews VA
23109-0327
US

V. Phone/Fax

Practice location:
  • Phone: 804-725-3041
  • Fax: 8047253510
Mailing address:
  • Phone: 804725-3041
  • Fax: 804-725-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyX
Taxonomy Code101YP2500X
Taxonomy101YP2500X
License Number0701001882
License Number StateVirginia
# 2
Primary TaxonomyX
Taxonomy Code106H00000X
Taxonomy106H00000X
License Number0717000854
License Number StateVirginia

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: