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General NPI Number Information
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NPI Number | 1700830742
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Entity Type | Organization
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Legal Business Name | TIDEWATER PSYCHOTHERAPY SERVICES
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Dates
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Enumeration Date | 05/22/2006
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Last Update Date | 08/21/2017
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Provider Practice Location Address
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Address Line | 260 GRAYSON RD SUITE 100
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-4345
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Country | US
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Telephone | 757-497-3670
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Fax | 757-499-1947
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Provider Business Mailing Address
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Address Line | 260 GRAYSON RD SUITE 100
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-4345
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Country | US
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Telephone | 757-497-3670
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Fax | 757-499-1947
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Authorized Official
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Title or Position | PRESIDENT, AUTHORIZAED OFFICAL
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Name | LOUISE FRIEDMAN
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Credential | LCSW
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Telephone | 757-497-3670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 204
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 2006112732R
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License Number State | VA
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