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General NPI Number Information
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NPI Number | 1275645939
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Entity Type | Organization
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Legal Business Name | TIDESIDE CLINICAL & PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 64 CHURCH ST TIDESIDE
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City | ELLSWORTH
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State | ME
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Zip | 04605-1658
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Country | US
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Telephone | 207-669-6011
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Fax | 207-669-6011
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Provider Business Mailing Address
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Address Line | 94 MILL ST
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City | ORONO
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State | ME
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Zip | 04473-4040
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Country | US
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Telephone | 207-866-2636
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Fax | 207-669-6011
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Authorized Official
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Title or Position | SOLE OWNER
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Name | MR. KENNETH A. BEATTIE
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Credential | PH.D.
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Telephone | 207-669-6011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PS1018
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License Number State | ME
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