Provider Demographics
NPI:1528178621
Name:TIDEWATER INSTITUTE OF NLP
Entity Type:Organization
Organization Name:TIDEWATER INSTITUTE OF NLP
Other - Org Name:PRIVATE PRACTICE OF PAMELA JO KAYANAN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:KAYANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED LPC LSATP LMFT
Authorized Official - Phone:757-643-8894
Mailing Address - Street 1:11747 JEFFERSON AVE
Mailing Address - Street 2:SUITE 6D
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1998
Mailing Address - Country:US
Mailing Address - Phone:757-643-8894
Mailing Address - Fax:757-643-8914
Practice Address - Street 1:11747 JEFFERSON AVE
Practice Address - Street 2:SUITE 6D
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1998
Practice Address - Country:US
Practice Address - Phone:757-643-8894
Practice Address - Fax:757-643-8914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000195101YA0400X
VA0701003183101YP2500X
VA0717001073106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA440869OtherANTHEM BCBS
VA2577110OtherCAQH