Tidewater Physical Therapy, LLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

Legal business name

TIDEWATER PHYSICAL THERAPY, LLC

Practice address

3510 Anderson Hwy
Suite 2
Powhatan, VA 23139

Phone

(804) 598-2100

Fax

(804) 598-7624

NPI assigned

Jun 30, 2009

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 3

Other names 1

• Pivot Physical Therapy of Virginia Doing business as

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

{
    "created_epoch": "1246320000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732492800000",
    "number": "1609004571",
    "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": "3510 ANDERSON HWY",
            "address_2": "SUITE 2",
            "city": "POWHATAN",
            "state": "VA",
            "postal_code": "23139",
            "telephone_number": "804-598-2100",
            "fax_number": "804-598-7624"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIDEWATER PHYSICAL THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-30",
        "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": "DEPT OF LABOR/ACS",
            "identifier": "223951124",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (PHYSICAL THERAPY)",
            "identifier": "1609004571",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS (OCCUPATIONAL THERAPY)",
            "identifier": "1609004571",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pivot Physical Therapy of Virginia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• William Harold Stewart Jr.
• Cristina Maria Story, DNP, FNP-C
• Kei Takahashi
• Martha M Talley, R.PH.
• Autumn Thompson, PHARMD
• Erin Tierney-Butler, LPC
• Michelle Lea Tiet, MSN-FNP
• Tiller Supported Living, LLC
• Gregg A Tobey, PT
• Tanya Torrijos, CCC-SLP

• Physical Therapist in Powhatan, VA
• Providers in Powhatan, 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.