MEDICARE: STRONG FOUNDATION YOUTH INITIATIVE - TIDEWATER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	806	VA

General Provider Information

NPI Number	:	1063747905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRONG FOUNDATION YOUTH INITIATIVE - TIDEWATER LLC

Provider Business Mailing Address
First Line	:	3634 S PLAZA TRL
Second Line	:	SUITE 201
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-3351
Country	:	US
Telephone Number	:	757-306-1390
Fax Number	:	757-306-1391

Provider Business Practice Location Address
First Line	:	3634 S PLAZA TRL
Second Line	:	SUITE 201
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-3351
Country	:	US
Telephone Number	:	757-306-1390
Fax Number	:	757-306-1391

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT ASHFORD
Credential	:	QMHP
Telephone Number	:	757-306-1390

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	10/09/2009

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