Provider Demographics
NPI:1700830742
Name:TIDEWATER PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:TIDEWATER PSYCHOTHERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, AUTHORIZAED OFFICAL
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-497-3670
Mailing Address - Street 1:260 GRAYSON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4345
Mailing Address - Country:US
Mailing Address - Phone:757-497-3670
Mailing Address - Fax:757-499-1947
Practice Address - Street 1:260 GRAYSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4345
Practice Address - Country:US
Practice Address - Phone:757-497-3670
Practice Address - Fax:757-499-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA204101YA0400X
VA2006112732R104100000X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1700830742Medicaid
CO1311Medicare PIN
VACO1311Medicare UPIN