Healthcare Provider Details

I. General information

NPI: 1407014509
Provider Name (Legal Business Name): TIDEWATER PASTORAL COUNSELING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 HAMPTON BLVD
NORFOLK VA
23505-2923
US

IV. Provider business mailing address

7305 HAMPTON BLVD
NORFOLK VA
23505-2923
US

V. Phone/Fax

Practice location:
  • Phone: 757-623-2700
  • Fax: 757-640-1058
Mailing address:
  • Phone: 757-623-2700
  • Fax: 757-640-1058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0701000401
License Number StateVA

VIII. Authorized Official

Name: MR. MARTIN W PHILLIPS
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 757-623-2700