Healthcare Provider Details

I. General information

NPI: 1285657874
Provider Name (Legal Business Name): TIDEWATER THERAPY FOR CHILDREN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 RAINTREE RD SUITE 240
CHESAPEAKE VA
23321-3700
US

IV. Provider business mailing address

4016 RAINTREE RD SUITE 240
CHESAPEAKE VA
23321-3700
US

V. Phone/Fax

Practice location:
  • Phone: 757-488-2864
  • Fax: 757-488-4735
Mailing address:
  • Phone: 757-488-2864
  • Fax: 757-488-4735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JESSICA ML DUPREE
Title or Position: OFFICE/INSURANCE MANAGER
Credential: BS
Phone: 757-488-2864