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General NPI Number Information
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NPI Number | 1689615296
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Entity Type | Organization
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Legal Business Name | WESTERN TIDEWATER COMMUNITY MENTAL
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 10/22/2025
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Provider Practice Location Address
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Address Line | 7025 HARBOUR VIEW BLVD STE 119
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City | SUFFOLK
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State | VA
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Zip | 23435-2762
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Country | US
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Telephone | 757-966-2805
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Fax | 757-673-2586
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Provider Business Mailing Address
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Address Line | 7025 HARBOUR VIEW BLVD STE 119
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City | SUFFOLK
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State | VA
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Zip | 23435-2762
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Country | US
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Telephone | 757-966-2805
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Fax | 757-673-2586
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Authorized Official
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Title or Position | REIMBURSEMENT SUPERVISOR
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Name | MARION YOUNG
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Credential |
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Telephone | 757-687-9087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171WH0202X
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Taxonomy Name | Home Modifications Contractor
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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 | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 333300000X
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Taxonomy Name | Emergency Response System Companies
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 084-16-001
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License Number State | VA
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Taxonomy #6
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | VA
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Taxonomy #9
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Taxonomy Code | 225CA2400X
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Taxonomy Name | Assistive Technology Practitioner Rehabilitation Counselor
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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