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General NPI Number Information
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NPI Number | 1215952361
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Entity Type | Organization
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Legal Business Name | TIDEWATER PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 4020 RAINTREE RD STE D
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City | CHESAPEAKE
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State | VA
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Zip | 23321-3749
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Country | US
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Telephone | 757-484-4241
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Fax | 757-484-4487
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Provider Business Mailing Address
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Address Line | 350 NEW FIDELITY CT
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City | GARNER
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State | NC
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Zip | 27529-2665
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Country | US
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Telephone | 919-258-2714
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Fax |
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Authorized Official
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Title or Position | MANAGER, CREDENTIALING
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Name | TASHEDA BROUGHTON
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Credential | PESC
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Telephone | 252-248-3313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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