Provider Demographics
NPI:1962196683
Name:THE CHANGING TIDE BODY MIND & SPIRIT PC DBA I CHOOSE LIFE INC.
Entity type:Organization
Organization Name:THE CHANGING TIDE BODY MIND & SPIRIT PC DBA I CHOOSE LIFE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE ZIEROW
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:804-725-3041
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-0327
Mailing Address - Country:US
Mailing Address - Phone:804-725-3041
Mailing Address - Fax:804-725-3510
Practice Address - Street 1:75 MAIN STREET
Practice Address - Street 2:STE E
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109
Practice Address - Country:US
Practice Address - Phone:804-725-3041
Practice Address - Fax:804-725-3510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CHANGING TIDE BODY, MIND & SPIRIT P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-06
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2019115759Medicaid
VAVVU978C639OtherMEDICARE