| Shifting Tides, Llc | |
|
6337 Central Ave Portage IN 46368-3801 | |
| (219) 763-1499 | |
| (219) 764-7025 |
| Full Name | Shifting Tides, Llc |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 6337 Central Ave, Portage, Indiana |
| Authorized Official Name and Position | Todd Snyder (OPERATING MEMBER) |
| Authorized Official Contact | 2197631499 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Shifting Tides, Llc 6337 Central Ave Portage IN 46368-3801 Ph: (219) 763-1499 | Shifting Tides, Llc 6337 Central Ave Portage IN 46368-3801 Ph: (219) 763-1499 |
| NPI Number | 1194965392 |
|---|---|
| Provider Enumeration Date | 02/27/2009 |
| Last Update Date | 02/27/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194965392 | NPI | - | NPPES |
| 200538700B | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 20042029A (Indiana) | Primary |
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