Healthcare Provider Details

I. General information

NPI: 1881032183
Provider Name (Legal Business Name): TIDEWATER THERAPEUTIC AFTERSCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SALTERS CREEK RD
HAMPTON VA
23661-2453
US

IV. Provider business mailing address

12 SALTERS CREEK RD
HAMPTON VA
23661-2453
US

V. Phone/Fax

Practice location:
  • Phone: 757-380-0194
  • Fax:
Mailing address:
  • Phone: 757-380-0194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1742
License Number StateVA

VIII. Authorized Official

Name: MS. PRINCETTA D WOOTEN
Title or Position: PRESIDENT
Credential:
Phone: 757-592-7584