Provider Demographics
NPI:1164416533
Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Entity Type:Organization
Organization Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:BOWE
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-255-7113
Mailing Address - Street 1:5268 GODWIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8135
Mailing Address - Country:US
Mailing Address - Phone:757-255-7100
Mailing Address - Fax:
Practice Address - Street 1:5268 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8135
Practice Address - Country:US
Practice Address - Phone:757-255-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904002622261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health