Healthcare Provider Details

I. General information

NPI: 1316450976
Provider Name (Legal Business Name): PATRICK R TIDWELL PH.D, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 I-65 PARKWAY
MONTGOMERY AL
36106-2860
US

IV. Provider business mailing address

3884 BERKSHIRE DR
MONTGOMERY AL
36109-1641
US

V. Phone/Fax

Practice location:
  • Phone: 404-989-2867
  • Fax:
Mailing address:
  • Phone: 334-787-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number251S00000X
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: