Healthcare Provider Details

I. General information

NPI: 1649362179
Provider Name (Legal Business Name): PEGGY LOUISE TIDMORE-WHITE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT ROOTS DR
NORTH LITTLE ROCK AR
72114-1709
US

IV. Provider business mailing address

5401 DREHER LN
LITTLE ROCK AR
72209-4804
US

V. Phone/Fax

Practice location:
  • Phone: 501-257-3325
  • Fax: 501-257-3182
Mailing address:
  • Phone: 501-257-3325
  • Fax: 501-257-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-1435
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: