1316188733 NPI number — TIDEWATER HEALTHCARE SERVICES, INC

Table of content: KYLIE KELLAS CLINE LMFT (NPI 1053847111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316188733 NPI number — TIDEWATER HEALTHCARE SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDEWATER HEALTHCARE SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316188733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1214 PROGRESSIVE DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-2848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-227-4047
Provider Business Mailing Address Fax Number:
757-227-4109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1214 PROGRESSIVE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-2848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-227-4047
Provider Business Practice Location Address Fax Number:
757-227-4109
Provider Enumeration Date:
03/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-227-4047

Provider Taxonomy Codes

  • Taxonomy code: 251F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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