Provider Demographics
NPI:1407014509
Name:TIDEWATER PASTORAL COUNSELING SERVICES, INC
Entity Type:Organization
Organization Name:TIDEWATER PASTORAL COUNSELING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-623-2700
Mailing Address - Street 1:7305 HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-2923
Mailing Address - Country:US
Mailing Address - Phone:757-623-2700
Mailing Address - Fax:757-640-1058
Practice Address - Street 1:7305 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-2923
Practice Address - Country:US
Practice Address - Phone:757-623-2700
Practice Address - Fax:757-640-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701000401101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty