Healthcare Provider Details

I. General information

NPI: 1689615296
Provider Name (Legal Business Name): WESTERN TIDEWATER COMMUNITY MENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 HARBOUR VIEW BLVD STE 119
SUFFOLK VA
23435-2762
US

IV. Provider business mailing address

7025 HARBOUR VIEW BLVD STE 119
SUFFOLK VA
23435-2762
US

V. Phone/Fax

Practice location:
  • Phone: 757-966-2805
  • Fax: 757-673-2586
Mailing address:
  • Phone: 757-966-2805
  • Fax: 757-673-2586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225CA2400X
TaxonomyAssistive Technology Practitioner Rehabilitation Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number084-16-001
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateVA

VIII. Authorized Official

Name: MARION YOUNG
Title or Position: REIMBURSEMENT SUPERVISOR
Credential:
Phone: 757-687-9087