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General NPI Number Information
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NPI Number | 1023762119
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Entity Type | Organization
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Legal Business Name | HIGH TIDE PSYCHIATRY, PLLC
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Dates
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Enumeration Date | 02/08/2022
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Last Update Date | 02/08/2022
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Provider Practice Location Address
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Address Line | 1500 PANCHERI DR STE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3212
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Country | US
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Telephone | 208-557-3870
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 PANCHERI DR STE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3212
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Country | US
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Telephone | 208-557-3870
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMBER JANE VAN SICKLE-BIRCH
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Credential | PMHNP
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Telephone | 208-557-3870
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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