Tide Life Therapy LLC

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

TIDE LIFE THERAPY LLC

Doing business as

Tide Life Therapy

Practice address

4 27TH Ave Apt a
Isle of Palms, SC 29451-2402

Phone

(843) 603-1213

NPI assigned

May 13, 2022

Last updated

May 13, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michaela Anne Buckhannon, LISW-CPNPI 1770174500

Title

Clinician

Phone

(843) 603-1213

Specialties & licenses 1

Addresses

Other names 1

• Tide Life Therapy Doing business as

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Michaela Buckhannon, LISW CP

  • Clinical Social Worker
  • Charleston, SC
  • NPI 1770174500
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1652400000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652400000000",
    "number": "1356088108",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 117",
            "city": "ISLE OF PALMS",
            "state": "SC",
            "postal_code": "294510117",
            "telephone_number": "843-603-1213"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4 27TH AVE APT A",
            "city": "ISLE OF PALMS",
            "state": "SC",
            "postal_code": "294512402",
            "telephone_number": "843-603-1213"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDE LIFE THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-13",
        "last_updated": "2022-05-13",
        "certification_date": "2022-05-13",
        "status": "A",
        "authorized_official_last_name": "BUCKHANNON",
        "authorized_official_first_name": "MICHAELA",
        "authorized_official_middle_name": "ANNE",
        "authorized_official_title_or_position": "CLINICIAN",
        "authorized_official_telephone_number": "843-603-1213",
        "authorized_official_credential": "LISW-CP"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tide Life Therapy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Elissa Reilly Slater, BSN RN
• Caroline Sledden, RDN, LDN
• Teeth DS Isle of Palms (Teeth DS IOP Endo Perio)
• Teeth DS Isle of Palms
• The Island Doctor
• Richard George Wagner Jr., M.D.
• Lindsay Williams, ED.S.

• Mental Health Clinic/Center (Including Community Mental Health Center) in Isle of Palms, SC
• Providers in Isle of Palms, SC by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.