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General NPI Number Information
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NPI Number | 1578224929
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Entity Type | Organization
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Legal Business Name | TIDALHEALTH SPECIALTY CARE, LLC
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Dates
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Enumeration Date | 01/07/2022
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 11101 CATHAGE RD UNIT 102
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City | BERLIN
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State | MD
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Zip | 21811-2115
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Country | US
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Telephone | 410-912-6104
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 825461
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City | PHILADELPHIA
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State | PA
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Zip | 19182
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Country | US
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Telephone | 410-912-6989
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Fax |
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | WILLIAM PELOT
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Credential |
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Telephone | 410-543-7497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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