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Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Organization
TIDEWATER PHYSICAL THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TASHEDA BROUGHTON PESC (MANGER, CREDENTIALING)
(252) 248-3313
Entity
Organization
Contact information
Practice address
4125 IRONBOUND RD, STE 100, WILLIAMSBURG, VA 23188-2666
(757) 220-8383
(757) 253-7833
Mailing address
2122 YORK RD STE 300, OAK BROOK, IL 60523-1925
(252) 248-3133
(410) 648-4878
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
225X00000X
Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
192935
BCBS (PT)
VA
01
—
192937
BCBS (OT)
VA
Enumeration date
07/19/2006
Last updated
11/25/2024
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