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NPI Code Detail

MEDICARE: TIDEWATER PSYCHOTHERAPY SERVICES

MEDICARE: TIDEWATER PSYCHOTHERAPY SERVICES
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
1101YA0400XAddiction (Substance Use Disorder) Counselor204VA
22084P0800XPsychiatry Physician
3104100000XSocial Worker2006112732RVA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1700830742
Entity Type Code : Organization
Provider Name (Legal Business Name) : TIDEWATER PSYCHOTHERAPY SERVICES
Provider Business Mailing Address
First Line : 260 GRAYSON RD
Second Line : SUITE 100
City : VIRGINIA BEACH
State : VA
Zip : 23462-4345
Country : US
Telephone Number : 757-497-3670
Fax Number : 757-499-1947
Provider Business Practice Location Address
First Line : 260 GRAYSON RD
Second Line : SUITE 100
City : VIRGINIA BEACH
State : VA
Zip : 23462-4345
Country : US
Telephone Number : 757-497-3670
Fax Number : 757-499-1947
Authorized Official
Title or Position : PRESIDENT, AUTHORIZAED OFFICAL
Name : LOUISE FRIEDMAN
Credential : LCSW
Telephone Number : 757-497-3670
Provider Enumeration Date : 05/22/2006
Last Update Date : 08/21/2017

Similar Medicare Providers

1124088638 — JEWISH FAMILY SERVICE OF TIDEWATER, INCORPORATED
Practice Location Address:
260 GRAYSON RD STE 200
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-459-4640
Practice Fax: 757-459-4643
1154356640 — MRS. MICHELLE MARLEY FENLEY MSW LCSW
Practice Location Address:
260 GRAYSON ROAD , JEWISH FAMILY SERVICE OF TIDEWATER INC
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-459-4640
Practice Fax: 757-459-4643
1063447555 — MS. LAURA MYERS KANTER MSW LCSW
Practice Location Address:
260 GRAYSON RD , JEWISH FAMILY SERVICE OF TIDEWATER INC
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-459-4640
Practice Fax: 757-459-4643
1962437467 — MS. DIANA G RUCHELMAN MSW, LCSW
Practice Location Address:
260 GRAYSON RD. , JEWISH FAMILY SERVICE OF TIDEWATER, INC.
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-459-4640
Practice Fax: 757-459-4643
1043236060 — MS. MICHELLE JOAN WALTER MSW, LCSW
Practice Location Address:
260 GRAYSON ROAD , JEWISH FAMILY SERVICE OF TIDEWATER INC
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-459-4640
Practice Fax: 757-459-4643
1164536496 — TIDEWATER PSYCHOTHERAPY SERVICES
Practice Location Address:
260 GRAYSON RD STE 100
VIRGINIA BEACH, VA
23462-4345
Practice Phone: 757-497-3670
Practice Fax: 757-499-1947

Directions to “TIDEWATER PSYCHOTHERAPY SERVICES ” Practice Location

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