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General NPI Number Information
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NPI Number | 1063747905
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Entity Type | Organization
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Legal Business Name | STRONG FOUNDATION YOUTH INITIATIVE - TIDEWATER LLC
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Dates
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Enumeration Date | 10/09/2009
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Last Update Date | 10/09/2009
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Provider Practice Location Address
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Address Line | 3634 S PLAZA TRL SUITE 201
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-3351
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Country | US
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Telephone | 757-306-1390
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Fax | 757-306-1391
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Provider Business Mailing Address
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Address Line | 3634 S PLAZA TRL SUITE 201
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-3351
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Country | US
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Telephone | 757-306-1390
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Fax | 757-306-1391
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Authorized Official
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Title or Position | CEO
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Name | MR. ROBERT ASHFORD
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Credential | QMHP
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Telephone | 757-306-1390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 806
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License Number State | VA
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