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Organization
TIDEWATER RECOVERY, PLC
Active
Organization
TIDEWATER RECOVERY, PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. SUSAN G HALLETT LCSW (OWNER/THERAPIST)
(804) 758-4242
Entity
Organization
Contact information
Practice address
55 CROSS STREET, URBANNA, VA 23175
(804) 758-4242
(615) 704-7447
Mailing address
PO BOX 1042, 55 CROSS STREET, URBANNA, VA 23175-1042
(804) 758-4242
(615) 704-7447
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
0904005105
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1205910460
NPI
VA
Enumeration date
04/09/2012
Last updated
04/09/2012
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