MEDICARE: RISING TIDE THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1477209328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISING TIDE THERAPY, LLC

Provider Business Mailing Address
First Line	:	7647 W GULF TO LAKE HWY STE 4
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-7800
Country	:	US
Telephone Number	:	352-212-7435
Fax Number	:

Provider Business Practice Location Address
First Line	:	7647 W GULF TO LAKE HWY STE 4
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-7800
Country	:	US
Telephone Number	:	352-212-7435
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAURIE-ANNE C KUZEL
Credential	:	LMHC
Telephone Number	:	352-634-1168

Provider Enumeration Date	:	03/01/2022
Last Update Date	:	03/01/2023

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Directions to “RISING TIDE THERAPY, LLC ” Practice Location

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