=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346015088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATER'S EDGE THERAPY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2023
-----------------------------------------------------
Last Update Date | 12/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229B MAIN ST
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-6119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-578-2244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1353 MERCER RD
-----------------------------------------------------
City | MERCER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04957-4469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. AMY M TARDY
-----------------------------------------------------
Credential | PHD, LCPC
-----------------------------------------------------
Telephone | 207-578-2244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------