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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
7493 RIGHT FLANK RD, SUITE 410, MECHANICSVILLE, VA 23116-3846
(804) 569-7091
(804) 569-7094
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
—
342325
BCBS OCCUPATIONAL THERAPY
VA
01
—
342327
BCBS PHYSICAL THERAPY
VA
Enumeration date
01/03/2008
Last updated
12/06/2024
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