Healthcare Provider Details

I. General information

NPI: 1558958991
Provider Name (Legal Business Name): TIDAL BALANCED WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 TACOMA AVE S STE 1
TACOMA WA
98402-2550
US

IV. Provider business mailing address

325 TACOMA AVE S STE 1
TACOMA WA
98402-2550
US

V. Phone/Fax

Practice location:
  • Phone: 757-921-7704
  • Fax:
Mailing address:
  • Phone: 757-921-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHANNON BARELLO CRAYTON
Title or Position: OWNER
Credential: LICSW
Phone: 757-921-7704