Healthcare Provider Details

I. General information

NPI: 1124060314
Provider Name (Legal Business Name): CLINICAL ASSOCIATES OF TIDEWATER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 N CENTER DR SUITE 101
NORFOLK VA
23502-4009
US

IV. Provider business mailing address

6320 N CENTER DR SUITE 101
NORFOLK VA
23502-4009
US

V. Phone/Fax

Practice location:
  • Phone: 757-456-0505
  • Fax: 757-456-0817
Mailing address:
  • Phone: 757-456-0505
  • Fax: 757-456-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA DEAN REID
Title or Position: PRESIDENT
Credential: LCSW
Phone: 757-456-0505