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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
6970 FOX HUNT LN, GLOUCESTER, VA 23061-5394
(804) 694-8111
(804) 694-5574
Mailing address
2122 YORK RD STE 300, OAK BROOK, IL 60523-1925
(252) 248-3313
(410) 678-4878
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
225X00000X
Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
192960
BCBS (PT)
VA
01
—
223951103
DOL
VA
Enumeration date
07/12/2006
Last updated
11/25/2024
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