Provider Demographics
NPI:1285657874
Name:TIDEWATER THERAPY FOR CHILDREN, PC
Entity Type:Organization
Organization Name:TIDEWATER THERAPY FOR CHILDREN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ML
Authorized Official - Last Name:DUPREE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:757-488-2864
Mailing Address - Street 1:4016 RAINTREE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3700
Mailing Address - Country:US
Mailing Address - Phone:757-488-2864
Mailing Address - Fax:757-488-4735
Practice Address - Street 1:4016 RAINTREE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:757-488-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194323OtherANTHEM BC & HK OT PROV #
VA57242OtherOPTIMA PROVIDER NUMBER
VA=========OtherTRICARE FACILITY PROV #
VA496668Medicare ID - Type UnspecifiedMEDICARE PROVIDER #