Healthcare Provider Details

I. General information

NPI: 1912610148
Provider Name (Legal Business Name): TIDE POOL COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 ARROWHEAD LANE
STUARTS DRAFT VA
24477
US

IV. Provider business mailing address

296 ARROWHEAD LANE
STUARTS DRAFT VA
24477
US

V. Phone/Fax

Practice location:
  • Phone: 540-241-5740
  • Fax:
Mailing address:
  • Phone: 540-241-5740
  • 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: KATHRYN ELIZABETH SNYDER
Title or Position: OWNER
Credential: LICSW, MPH
Phone: 540-241-5740