Provider Demographics
NPI:1689568404
Name:TIDALHEALTH PEDIATRIC DEVELOPMENT AND THERAPY LLC
Entity type:Organization
Organization Name:TIDALHEALTH PEDIATRIC DEVELOPMENT AND THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAZMINE
Authorized Official - Middle Name:MAREE
Authorized Official - Last Name:HOLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-799-6824
Mailing Address - Street 1:30265 COMMERCE DR UNIT 204
Mailing Address - Street 2:
Mailing Address - City:MILLSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19966-3595
Mailing Address - Country:US
Mailing Address - Phone:443-978-6020
Mailing Address - Fax:
Practice Address - Street 1:30265 COMMERCE DR UNIT 204
Practice Address - Street 2:
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-3595
Practice Address - Country:US
Practice Address - Phone:443-978-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty