Healthcare Provider Details

I. General information

NPI: 1669085296
Provider Name (Legal Business Name): ALEXIS TIDBALL ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DOWNEY AVE
MODESTO CA
95354-1208
US

IV. Provider business mailing address

1438 E J ST
OAKDALE CA
95361-8862
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax:
Mailing address:
  • Phone: 209-247-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number98746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: