Healthcare Provider Details

I. General information

NPI: 1134001159
Provider Name (Legal Business Name): CRYSTAL LYNN TIDWELL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2466 S 48TH ST
SPRINGDALE AR
72762-6683
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-750-2020
  • Fax: 479-750-8967
Mailing address:
  • Phone: 479-750-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberPLMSW
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: