Provider Demographics
NPI:1881032183
Name:TIDEWATER THERAPEUTIC AFTERSCHOOL
Entity Type:Organization
Organization Name:TIDEWATER THERAPEUTIC AFTERSCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PRINCETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-592-7584
Mailing Address - Street 1:12 SALTERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-2453
Mailing Address - Country:US
Mailing Address - Phone:757-380-0194
Mailing Address - Fax:
Practice Address - Street 1:12 SALTERS CREEK RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-2453
Practice Address - Country:US
Practice Address - Phone:757-380-0194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1742251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health