Provider Demographics
NPI:1578970927
Name:TIDEWATER CHILD AND FAMILY BEHAVIORAL HEALTH CENTER, PLLC
Entity Type:Organization
Organization Name:TIDEWATER CHILD AND FAMILY BEHAVIORAL HEALTH CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-994-1875
Mailing Address - Street 1:1000 REGENT UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5037
Mailing Address - Country:US
Mailing Address - Phone:757-352-4377
Mailing Address - Fax:
Practice Address - Street 1:1000 REGENT UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5037
Practice Address - Country:US
Practice Address - Phone:757-352-4377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004375103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty