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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 (CREDENTIALING MANAGER)
(252) 248-3313
Entity
Organization
Contact information
Practice address
751 J CLYDE MORRIS BLVD, NEWPORT NEWS, VA 23601-1538
(757) 873-2123
(757) 873-3848
Mailing address
2122 YORK RD STE 300, OAK BROOK, IL 60523-1925
(630) 575-1980
(630) 928-5080
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
225X00000X
Occupational Therapist
—
—
261Q00000X
Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
192931
BCBS (PT)
VA
Enumeration date
07/21/2006
Last updated
11/19/2024
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