1114762788 NPI number — SHIFTING TIDES THERAPY LMSW, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114762788 NPI number — SHIFTING TIDES THERAPY LMSW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIFTING TIDES THERAPY LMSW, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114762788
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
767 BROADWAY
Provider Second Line Business Mailing Address:
#1327
Provider Business Mailing Address City Name:
MANHATTAN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-664-0647
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 DR MLK JR ST S
Provider Second Line Business Practice Location Address:
UNIT 405
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-664-0647
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2024

Additional Information

Authorized Official

Authorized Official Last Name:
DOHERTY
Authorized Official First Name:
DEANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
781-664-0647

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1336780295 . This is a "MY PERSONAL NPI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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