Healthcare Provider Details

I. General information

NPI: 1659623833
Provider Name (Legal Business Name): TONYA TIDWELL LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TONYA MCFARLAND

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 EXCHANGE AVE STE 103
CONWAY AR
72032-7833
US

IV. Provider business mailing address

35 GOFF ST
VILONIA AR
72173-9315
US

V. Phone/Fax

Practice location:
  • Phone: 501-781-2230
  • Fax: 870-972-4911
Mailing address:
  • Phone: 479-567-1858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2508009
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA2205009
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: