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NPI Code Detail

MEDICARE: TIDEWATER THERAPY FOR CHILDREN, PC

MEDICARE: TIDEWATER THERAPY FOR CHILDREN, PC
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
1235Z00000XSpeech-Language Pathologist

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
157442OTHERVAOPTIMA ST PROVIDER #
2194324OTHERVAANTHEM BC & HK ST PROV #

General Provider Information

NPI Number : 1174549000
Entity Type Code : Organization
Provider Name (Legal Business Name) : TIDEWATER THERAPY FOR CHILDREN, PC
Provider Business Mailing Address
First Line : 4016 RAINTREE RD
Second Line : SUITE 240
City : CHESAPEAKE
State : VA
Zip : 23321-3700
Country : US
Telephone Number : 757-488-2864
Fax Number : 757-488-4735
Provider Business Practice Location Address
First Line : 4016 RAINTREE RD
Second Line : SUITE 240
City : CHESAPEAKE
State : VA
Zip : 23321-3700
Country : US
Telephone Number : 757-488-2864
Fax Number : 757-488-4735
Authorized Official
Title or Position : OFFICE/INSURANCE MANAGER
Name : MRS. JESSICA ML DUPREE
Credential : BS
Telephone Number : 757-488-2864
Provider Enumeration Date : 07/14/2006
Last Update Date : 08/22/2020

Similar Medicare Providers

1316051287 — TIDEWATER THERAPY FOR CHILDREN, PC
Practice Location Address:
4016 RAINTREE RD , SUITE 240
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax: 757-488-4735
1245256825 — MRS. PATRICE KAINRATH MA, CCC-SLP
Practice Location Address:
4016 RAINTREE RD , SUITE 240
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax: 757-488-4735
1447276035 — MRS. CHRISTY SURGEONER OTR/L
Practice Location Address:
4016 RAINTREE RD , SUITE 240
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax: 757-488-4735
1407872005 — MR. STEPHEN A FAHERTY OTR/L
Practice Location Address:
4016 RAINTREE RD , SUITE 240
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax: 757-488-4735
1194744888 — MRS. MICHELLE P POWERS MS, CCC-SLP
Practice Location Address:
4016 RAINTREE RD
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax:
1174542864 — MRS. LORI L STEELE MS, CCC-SLP
Practice Location Address:
4016 RAINTREE RD , SUITE 240
CHESAPEAKE, VA
23321-3700
Practice Phone: 757-488-2864
Practice Fax: 757-488-4735

Directions to “TIDEWATER THERAPY FOR CHILDREN, PC ” Practice Location

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