Tidewater Physical Therapy LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

Legal business name

TIDEWATER PHYSICAL THERAPY LLC

Practice address

9980 Brook Rd
Unit 16
Glen Allen, VA 23059-6501

Phone

(804) 550-5730

Fax

(804) 550-5733

NPI assigned

Jul 12, 2006

Last updated

Nov 25, 2024By the provider in NPPES

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": "1152662400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1386679595",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "350 NEW FIDELITY CT",
            "city": "GARNER",
            "state": "NC",
            "postal_code": "275292665",
            "telephone_number": "919-258-2714",
            "fax_number": "410-648-4878"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9980 BROOK RD",
            "address_2": "UNIT 16",
            "city": "GLEN ALLEN",
            "state": "VA",
            "postal_code": "230596501",
            "telephone_number": "804-550-5730",
            "fax_number": "804-550-5733"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-12",
        "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 (PT)",
            "identifier": "192969",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (OT)",
            "identifier": "192970",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Elaine Gray Thompson, MSOT
• James Edward Thompson, MD
• Laura Thornton, PT
• Andrew Thorpe, DPT
• Suzanne Coburn Throckmorton, LPC
• Tidewater Physical Therapy, LLC (Pivot Physical Therapy of Virginia)
• Tidewater Physical Therapy, LLC
• Sandra Rexrode Timok, PT, PCS
• Michael Maurice Tiomno
• TLN Professional Services PLLC

• Physical Therapist in Glen Allen, VA
• Providers in Glen Allen, 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.