Provider Demographics
NPI:1669558813
Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Entity type:Organization
Organization Name:WESTERN TIDEWATER COMMUNITY SERVICES BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PERATSAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-255-7127
Mailing Address - Street 1:5268 GODWIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8135
Mailing Address - Country:US
Mailing Address - Phone:757-255-7127
Mailing Address - Fax:
Practice Address - Street 1:130 SUBURBAN DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-2625
Practice Address - Country:US
Practice Address - Phone:757-255-7127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities