Provider Demographics
NPI:1174304190
Name:CHANGING TIDES WELLNESS CENTER LLC
Entity type:Organization
Organization Name:CHANGING TIDES WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCADC
Authorized Official - Phone:856-217-9182
Mailing Address - Street 1:199 NORTH WOODBURY RD.
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071
Mailing Address - Country:US
Mailing Address - Phone:856-508-0977
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR E STE 2
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1566
Practice Address - Country:US
Practice Address - Phone:856-508-0977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty