=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437818770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIDEMARK INTERVENTION SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2021
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7822 EASTERN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21224-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-596-8178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7822 EASTERN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21224-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-596-8178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | RYNE LAXTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-417-7385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------