Provider Demographics
NPI:1477303790
Name:WATERSIDE PSYCHIATRY LLC
Entity Type:Organization
Organization Name:WATERSIDE PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBOLU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-737-3134
Mailing Address - Street 1:721 REDLEAFE CIR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3226
Mailing Address - Country:US
Mailing Address - Phone:757-209-4607
Mailing Address - Fax:430-224-0004
Practice Address - Street 1:425 W WASHINGTON ST STE 4
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-5320
Practice Address - Country:US
Practice Address - Phone:757-209-4607
Practice Address - Fax:430-224-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty