=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477209328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RISING TIDE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2022
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7647 W GULF TO LAKE HWY STE 4
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-212-7435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7647 W GULF TO LAKE HWY STE 4
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-7800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-212-7435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAURIE-ANNE C KUZEL
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 352-634-1168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------