Provider Demographics
NPI:1992208367
Name:COASTAL COUNSELING CENTER OF TIDEWATER
Entity Type:Organization
Organization Name:COASTAL COUNSELING CENTER OF TIDEWATER
Other - Org Name:STACIA CHAPMAN-GOREY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPMAN-GOREY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-345-6428
Mailing Address - Street 1:215 MCLAWS CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5799
Mailing Address - Country:US
Mailing Address - Phone:757-345-6428
Mailing Address - Fax:757-345-6808
Practice Address - Street 1:215 MCLAWS CIR STE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5799
Practice Address - Country:US
Practice Address - Phone:757-345-6428
Practice Address - Fax:757-345-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904009449104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194862813OtherINDIVIDUAL NPI