Provider Demographics
NPI:1922679927
Name:TIDEWATER BEHAVIOR PROJECT
Entity Type:Organization
Organization Name:TIDEWATER BEHAVIOR PROJECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:757-778-8886
Mailing Address - Street 1:31 ARLINE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-2256
Mailing Address - Country:US
Mailing Address - Phone:757-778-8886
Mailing Address - Fax:
Practice Address - Street 1:31 ARLINE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-2256
Practice Address - Country:US
Practice Address - Phone:757-778-8886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty