Tidewater Physical Therapy, LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

Legal business name

TIDEWATER PHYSICAL THERAPY, LLC

Practice address

2004 Sandbridge Rd
Suite 102
Virginia Beach, VA 23456-4084

Phone

(757) 301-6316

Fax

(757) 301-6419

NPI assigned

Nov 7, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tasheda Broughton, PESC

Title

Manager, Credentialing

Phone

(252) 248-3313

Specialties & licenses 2

Addresses

Other identifiers 2

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1265501696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2122 YORK RD STE 300",
            "city": "OAK BROOK",
            "state": "IL",
            "postal_code": "605231925",
            "telephone_number": "252-248-3313",
            "fax_number": "410-648-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2004 SANDBRIDGE RD",
            "address_2": "SUITE 102",
            "city": "VIRGINIA BEACH",
            "state": "VA",
            "postal_code": "234564084",
            "telephone_number": "757-301-6316",
            "fax_number": "757-301-6419"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-07",
        "last_updated": "2024-11-25",
        "certification_date": "2024-11-25",
        "status": "A",
        "authorized_official_last_name": "BROUGHTON",
        "authorized_official_first_name": "TASHEDA",
        "authorized_official_title_or_position": "MANAGER, CREDENTIALING",
        "authorized_official_telephone_number": "252-248-3313",
        "authorized_official_credential": "PESC"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (OT)",
            "identifier": "247663",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (PT)",
            "identifier": "247660",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Tidewater Pca Training
• Tidewater Ped. Consultants, PC
• Tidewater Pelvic Health
• Tidewater Physical Therapy, LLC (Pivot Physical Therapy of Virginia)
• Tidewater Physical Therapy, LLC
• Tidewater Podiatry Group
• Tidewater Psychotherapy Services
• Tidewater Psychotherapy Services
• Tidewater Rehabilitation Medicine
• Tidewater Skin Care and Pathology PC

• Physical Therapist in Virginia Beach, VA
• Providers in Virginia Beach, VA by specialty
• Physical Therapist in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 25, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.