Healthcare Provider Details

I. General information

NPI: 1164536496
Provider Name (Legal Business Name): TIDEWATER PSYCHOTHERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 GRAYSON RD STE 100
VIRGINIA BEACH VA
23462-4345
US

IV. Provider business mailing address

260 GRAYSON RD STE 100
VIRGINIA BEACH VA
23462-4345
US

V. Phone/Fax

Practice location:
  • Phone: 757-497-3670
  • Fax: 757-499-1947
Mailing address:
  • Phone: 757-497-3670
  • Fax: 757-499-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number204
License Number StateVA

VIII. Authorized Official

Name: MRS. LOUISE B FRIEDMAN
Title or Position: PRESIDENT
Credential: LCSW
Phone: 757-497-3670