Healthcare Provider Details

I. General information

NPI: 1548890544
Provider Name (Legal Business Name): MICHAEL TIDSTRAND BA, MA, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2020
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20112 RUNNYMEDE ST UNIT 5
WINNETKA CA
91306-2901
US

IV. Provider business mailing address

20112 RUNNYMEDE ST UNIT 5
WINNETKA CA
91306-2901
US

V. Phone/Fax

Practice location:
  • Phone: 818-216-0321
  • Fax:
Mailing address:
  • Phone: 818-216-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC7019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: