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General NPI Number Information
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NPI Number | 1649076191
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Entity Type | Organization
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Legal Business Name | DEEP TIDES THERAPY PLLC
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Dates
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Enumeration Date | 02/24/2025
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Last Update Date | 02/24/2025
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Provider Practice Location Address
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Address Line | 1804 E 18TH ST
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City | GEORGETOWN
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State | TX
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Zip | 78626-7322
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Country | US
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Telephone | 503-754-2817
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Fax |
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Provider Business Mailing Address
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Address Line | 14205 N MO PAC EXPY STE 570
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City | AUSTIN
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State | TX
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Zip | 78728-6529
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER OF ENTITY
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Name | CORINA WOLFENSTEIN
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Credential |
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Telephone | 503-754-2817
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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