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General NPI Number Information
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NPI Number | 1609168384
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Entity Type | Organization
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Legal Business Name | TIDES PSYCHOTHERAPY SERVICES, LLC
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Dates
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Enumeration Date | 05/12/2011
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Last Update Date | 05/12/2011
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Provider Practice Location Address
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Address Line | 900 DARLINGTON AVENUE
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City | MAHWAH
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State | NJ
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Zip | 07430
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Country | US
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Telephone | 973-699-6916
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Fax |
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Provider Business Mailing Address
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Address Line | 6 VAIL STREET
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City | NUTLEY
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State | NJ
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Zip | 07110
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Country | US
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Telephone | 973-699-6916
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Fax |
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Authorized Official
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Title or Position | OWNER/ PSYCHOTHERAPIST
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Name | TARA M DUBLANICA
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Credential | LCSW
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Telephone | 973-699-6916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC05284000
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License Number State | NJ
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