Provider Demographics
NPI:1093223968
Name:TIDEWATER COUNSELING GROUP, LLC
Entity Type:Organization
Organization Name:TIDEWATER COUNSELING GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NNEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MPA, QMHP-A, CEO
Authorized Official - Phone:757-753-6399
Mailing Address - Street 1:12695 MCMANUS BLVD BLDG 7B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4476
Mailing Address - Country:US
Mailing Address - Phone:757-753-6399
Mailing Address - Fax:757-527-4493
Practice Address - Street 1:12695 MCMANUS BLVD BLDG 7B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4476
Practice Address - Country:US
Practice Address - Phone:757-753-6399
Practice Address - Fax:757-527-4493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health