Provider Demographics
NPI:1871999565
Name:TIDAL NEUROPSYCHOLOGY PLLC
Entity type:Organization
Organization Name:TIDAL NEUROPSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRIFFIN
Authorized Official - Middle Name:POLLOCK
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-803-1434
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-0970
Mailing Address - Country:US
Mailing Address - Phone:910-803-1434
Mailing Address - Fax:855-672-7002
Practice Address - Street 1:19 S HAMPSTEAD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-3934
Practice Address - Country:US
Practice Address - Phone:910-803-1434
Practice Address - Fax:855-672-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-07
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4633103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty