MEDICARE: TIDAL NEUROPSYCHOLOGY PLLC

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	103TC0700X	Clinical Psychologist	4633	NC
2	103G00000X	Clinical Neuropsychologist	4633	NC

General Provider Information

NPI Number	:	1871999565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDAL NEUROPSYCHOLOGY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 970
Second Line	:
City	:	HAMPSTEAD
State	:	NC
Zip	:	28443-0970
Country	:	US
Telephone Number	:	910-803-1434
Fax Number	:	855-672-7002

Provider Business Practice Location Address
First Line	:	19 S HAMPSTEAD VILLAGE DR
Second Line	:
City	:	HAMPSTEAD
State	:	NC
Zip	:	28443-3934
Country	:	US
Telephone Number	:	910-803-1434
Fax Number	:	855-672-7002

Authorized Official
Title or Position	:	OWNER, MEMBER
Name	:	DR. GRIFFIN POLLOCK SUTTON
Credential	:	PH.D.
Telephone Number	:	910-803-1434

Provider Enumeration Date	:	11/07/2014
Last Update Date	:	11/07/2014

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