Healthcare Provider Details

I. General information

NPI: 1639767981
Provider Name (Legal Business Name): TIDEWATER AUTISM CONSULTATION AND THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6676 MAGNOLIA DR
GLOUCESTER VA
23061-4239
US

IV. Provider business mailing address

6676 MAGNOLIA DR
GLOUCESTER VA
23061-4239
US

V. Phone/Fax

Practice location:
  • Phone: 757-604-3394
  • Fax:
Mailing address:
  • Phone: 757-604-3394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH D LEGG
Title or Position: BEHAVIOR ANALYSY
Credential: MA, BCBA, LBA
Phone: 757-604-3394