Provider Demographics
NPI:1205155108
Name:TIDEWATER COUNSELING PLLC
Entity type:Organization
Organization Name:TIDEWATER COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:CAMPBELL
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:252-229-9053
Mailing Address - Street 1:5126 CHALK ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2559
Mailing Address - Country:US
Mailing Address - Phone:252-229-9053
Mailing Address - Fax:
Practice Address - Street 1:5126 CHALK ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2559
Practice Address - Country:US
Practice Address - Phone:252-229-9053
Practice Address - Fax:252-648-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty