Healthcare Provider Details

I. General information

NPI: 1528087616
Provider Name (Legal Business Name): ASSOCIATED COUNSELORS OF TIDEWATER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

287 INDEPENDENCE BLVD STE 219
VIRGINIA BEACH VA
23462-2956
US

IV. Provider business mailing address

287 INDEPENDENCE BLVD STE 219
VIRGINIA BEACH VA
23462-2956
US

V. Phone/Fax

Practice location:
  • Phone: 757-490-6960
  • Fax: 757-490-6995
Mailing address:
  • Phone: 757-490-6960
  • Fax: 757-490-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number07010001157
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002379
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002454
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000866
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000080
License Number StateVA

VIII. Authorized Official

Name: MS. CHRISTIANNE HARMON
Title or Position: OFFICE MANAGER
Credential:
Phone: 757-490-6960