MEDICARE: TIDEWATER COUNSELING GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1093223968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIDEWATER COUNSELING GROUP, LLC

Provider Business Mailing Address
First Line	:	12695 MCMANUS BLVD BLDG 7B
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-4476
Country	:	US
Telephone Number	:	757-753-6399
Fax Number	:	757-527-4493

Provider Business Practice Location Address
First Line	:	12695 MCMANUS BLVD BLDG 7B
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-4476
Country	:	US
Telephone Number	:	757-753-6399
Fax Number	:	757-527-4493

Authorized Official
Title or Position	:	CEO
Name	:	NNEKA BARTLETT
Credential	:	BS, MPA, QMHP-A, CEO
Telephone Number	:	757-753-6399

Provider Enumeration Date	:	01/13/2018
Last Update Date	:	01/13/2018

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