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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 (MANAGER, CREDENTIALING)
(252) 248-3313
Entity
Organization
Contact information
Practice address
2004 SANDBRIDGE RD, SUITE 102, VIRGINIA BEACH, VA 23456-4084
(757) 301-6316
(757) 301-6419
Mailing address
2122 YORK RD STE 300, OAK BROOK, IL 60523-1925
(252) 248-3313
(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
—
247660
BCBS (PT)
VA
01
—
247663
BCBS (OT)
VA
Enumeration date
11/07/2006
Last updated
11/25/2024
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