Healthcare Provider Details

I. General information

NPI: 1528178621
Provider Name (Legal Business Name): TIDEWATER INSTITUTE OF NLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11747 JEFFERSON AVE SUITE 6D
NEWPORT NEWS VA
23606-1998
US

IV. Provider business mailing address

11747 JEFFERSON AVE SUITE 6D
NEWPORT NEWS VA
23606-1998
US

V. Phone/Fax

Practice location:
  • Phone: 757-643-8894
  • Fax: 757-643-8914
Mailing address:
  • Phone: 757-643-8894
  • Fax: 757-643-8914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0718000195
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001073
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003183
License Number StateVA

VIII. Authorized Official

Name: MRS. PAMELA JO KAYANAN
Title or Position: PRESIDENT
Credential: MED LPC LSATP LMFT
Phone: 757-643-8894