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General NPI Number Information
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NPI Number | 1073989240
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Entity Type | Organization
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Legal Business Name | TIDEWATER SPEECH AND LANGUAGE SERVICES
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Dates
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Enumeration Date | 08/11/2015
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Last Update Date | 08/11/2015
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Provider Practice Location Address
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Address Line | 110 KINGSLEY LN SUITE 209
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City | NORFOLK
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State | VA
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Zip | 23505-4614
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Country | US
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Telephone | 757-423-1933
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Fax |
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Provider Business Mailing Address
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Address Line | 110 KINGSLEY LN SUITE 209
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City | NORFOLK
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State | VA
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Zip | 23505-4614
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | PAMELA CRENSHAW
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Credential | MA CCC-SLP
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Telephone | 757-423-1933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2202006671
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License Number State | VA
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