Provider Demographics
NPI:1154014116
Name:TIDES MENTAL HEALTH OF IL, PLLC
Entity type:Organization
Organization Name:TIDES MENTAL HEALTH OF IL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-391-6845
Mailing Address - Street 1:3000 N HALSTED ST STE 803
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6185
Mailing Address - Country:US
Mailing Address - Phone:312-391-6845
Mailing Address - Fax:
Practice Address - Street 1:3000 N HALSTED ST STE 803
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6185
Practice Address - Country:US
Practice Address - Phone:312-391-6845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty