Healthcare Provider Details

I. General information

NPI: 1881133791
Provider Name (Legal Business Name): TIDEWATER PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 09/02/2025
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MARKET ST SUITE B
PALMYRA VA
22963-4687
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 434-510-7301
  • Fax: 434-510-7418
Mailing address:
  • Phone: 252-248-3313
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateVA

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: MANAGER, CREDENTIALING
Credential: PESC
Phone: 252-248-3313