Healthcare Provider Details

I. General information

NPI: 1366956096
Provider Name (Legal Business Name): NEUROPSYCHOLOGICAL SERVICES OF TIDEWATER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 PLEASURE HOUSE RD
VIRGINIA BEACH VA
23455
US

IV. Provider business mailing address

2005 PLEASURE HOUSE RD
VIRGINIA BEACH VA
23455-2709
US

V. Phone/Fax

Practice location:
  • Phone: 757-301-2248
  • Fax: 757-689-8378
Mailing address:
  • Phone: 757-301-2248
  • Fax: 757-689-8378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810004265
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMIE DUCHARME
Title or Position: CLINICAL NEUROPSYCHOLOGIST
Credential: PHD
Phone: 757-301-2248