Provider Demographics
NPI:1114762788
Name:SHIFTING TIDES THERAPY LMSW, PLLC
Entity type:Organization
Organization Name:SHIFTING TIDES THERAPY LMSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:781-664-0647
Mailing Address - Street 1:767 BROADWAY
Mailing Address - Street 2:#1327
Mailing Address - City:MANHATTAN
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:781-664-0647
Mailing Address - Fax:
Practice Address - Street 1:555 DR MLK JR ST S
Practice Address - Street 2:UNIT 405
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705
Practice Address - Country:US
Practice Address - Phone:781-664-0647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336780295OtherMY PERSONAL NPI