Healthcare Provider Details

I. General information

NPI: 1043368186
Provider Name (Legal Business Name): ANDREW ROBESON TIDRICK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 W MAGNOLIA ST SUITE 120
FORT COLLINS CO
80521-2811
US

IV. Provider business mailing address

219 W MAGNOLIA ST SUITE 120
FORT COLLINS CO
80521-2811
US

V. Phone/Fax

Practice location:
  • Phone: 512-691-6025
  • Fax: 877-226-2395
Mailing address:
  • Phone: 512-691-6025
  • Fax: 877-226-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27843
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09923286
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: