Basic Information
Provider Information
NPI: 1558962688
EntityType: 2
ReplacementNPI:  
OrganizationName: SPRING TIDE COUNSELING PLLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: WOMEN'S INTEGRATIVE COUNSELING
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 314 WALNUT ST STE 109
Address2:  
City: WILMINGTON
State: NC
PostalCode: 284014160
CountryCode: US
TelephoneNumber: 9103336134
FaxNumber: 9103434227
Practice Location
Address1: 314 WALNUT ST STE 109
Address2:  
City: WILMINGTON
State: NC
PostalCode: 284014160
CountryCode: US
TelephoneNumber: 9103336134
FaxNumber: 9103434227
Other Information
ProviderEnumerationDate: 11/04/2020
LastUpdateDate: 11/10/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: RODGERS
AuthorizedOfficialFirstName: LAUREN
AuthorizedOfficialMiddleName: ELIZABETH
AuthorizedOfficialTitleorPosition: THERAPIST, OWNER
AuthorizedOfficialTelephone: 9103336134
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
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AuthorizedOfficialCredential: MA, LCMHC, LCAS
NPICertificationDate: 11/10/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  N193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YP2500X  Y193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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