WESTERN TIDEWATER COMMUNITY MENTAL

Provider Demographics

• NPI: 1689615296
• Name: WESTERN TIDEWATER COMMUNITY MENTAL
• Entity Type: Organization
• Organization Name: WESTERN TIDEWATER COMMUNITY MENTAL
• Other - Org Name: WESTERN TIDEWATER COMMUNITY SERVICES BOARD
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: REIMBURSEMENT SUPERVISOR
• Authorized Official - First Name: MARION
• Authorized Official - Last Name: YOUNG
• Authorized Official - Phone: 757-687-9087
• Mailing Address - Street 1: 7025 HARBOUR VIEW BLVD STE 119
• Mailing Address - City: SUFFOLK
• Mailing Address - State: VA
• Mailing Address - Zip Code: 23435-2762
• Mailing Address - Country: US
• Mailing Address - Phone: 757-966-2805
• Mailing Address - Fax: 757-673-2586
• Practice Address - Street 1: 7025 HARBOUR VIEW BLVD STE 119
• Practice Address - City: SUFFOLK
• Practice Address - State: VA
• Practice Address - Zip Code: 23435-2762
• Practice Address - Country: US
• Practice Address - Phone: 757-966-2805
• Practice Address - Fax: 757-673-2586
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-08
• Last Update Date: 2023-05-17

Provider Licenses

State	License ID	Taxonomies
VA	084-16-001	251B00000X
		251C00000X, 253Z00000X, 261QM0801X
VA	084-03-002	261QM0801X, 261QM0850X
VA	084-02-029	261QM0855X
VA		343900000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)
No	251B00000X	Agencies	Case Management
No	251C00000X	Agencies	Day Training, Developmentally Disabled Services
No	253Z00000X	Agencies	In Home Supportive Care
No	261QM0850X	Ambulatory Health Care Facilities	Clinic/Center	Adult Mental Health
No	261QM0855X	Ambulatory Health Care Facilities	Clinic/Center	Adolescent and Children Mental Health
No	343900000X	Transportation Services	Non-emergency Medical Transport (VAN)

Provider Identifiers

State	Identifier ID	ID Type	Issuer
VA	270369	Other	ANTHEM GROUP NUMBER
VA	004945310	Medicaid
VA	1689615296	Medicaid
VA	G22546	Medicare UPIN
	260002945	Medicare PIN
VA	B08925	Medicare UPIN
	260002952	Medicare PIN
VA	004945310	Medicaid
VA	R65129	Medicare UPIN
	260002914	Medicare PIN
	260002941	Medicare PIN
VA	270369	Other	ANTHEM GROUP NUMBER
VA	S02351	Medicare UPIN
VA	260002922	Medicare PIN
	260003031	Medicare PIN
VA	S54718	Medicare UPIN
	800002077	Medicare PIN
VA	001780W80	Medicare PIN
VA	R65129	Medicare UPIN
VA	C04522	Medicare ID - Type Unspecified
VA	001780W80	Medicare PIN