{
"Npi": {
"NPI": "1811273568",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "TIDES OF CHANGE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "333 W WILCOX DR",
"SecondLineMailingAddress": "STE. 303",
"MailingAddressCityName": "SIERRA VISTA",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85635-1789",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "520-458-2250",
"MailingAddressFaxNumber": "520-458-2269",
"FirstLinePracticeLocationAddress": "333 W WILCOX DR",
"SecondLinePracticeLocationAddress": "STE. 303",
"PracticeLocationAddressCityName": "SIERRA VISTA",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85635-1789",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "520-458-2250",
"PracticeLocationAddressFaxNumber": "520-458-2269",
"EnumerationDate": "10/26/2011",
"LastUpdateDate": "10/26/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "VALLADARES",
"AuthorizedOfficialFirstName": "MARIANNE",
"AuthorizedOfficialMiddleName": "S",
"AuthorizedOfficialTitle": "CEO/PARTNER",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LCSW",
"AuthorizedOfficialTelephoneNumber": "520-458-2250",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101Y00000X",
"TaxonomyName": "Counselor",
"LicenseNumber": "LPC12687",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YA0400X",
"TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
"LicenseNumber": "LISAC10504",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "LMSW",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "LCSW12394",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "LCSW2922",
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "LCSW2811",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "1041C0700X",
"TaxonomyName": "Clinical Social Worker",
"LicenseNumber": "LCSW10948",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
]
}
}
}