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General NPI Number Information
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NPI Number | 1730007782
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Entity Type | Organization
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Legal Business Name | RISING TIDE LICENSED CLINICAL SOCIAL WORKER A PROFESSIONAL CORP
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Dates
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Enumeration Date | 07/08/2026
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Last Update Date | 07/08/2026
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Provider Practice Location Address
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Address Line | 249 MORNING SUN AVE
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City | MILL VALLEY
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State | CA
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Zip | 94941-3503
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Country | US
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Telephone | 309-868-3809
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Fax |
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Provider Business Mailing Address
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Address Line | 249 MORNING SUN AVE
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City | MILL VALLEY
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State | CA
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Zip | 94941-3503
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Country | US
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Telephone | 309-868-3809
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | LUCAS MICHAEL GARRISON
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Credential | LCSW
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Telephone | 309-868-3809
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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 |
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License Number State |
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