Healthcare Provider Details

I. General information

NPI: 1184905911
Provider Name (Legal Business Name): LYNN B TIDGWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 WEST ST
DANBURY CT
06810-6528
US

IV. Provider business mailing address

75 WEST ST
DANBURY CT
06810-6528
US

V. Phone/Fax

Practice location:
  • Phone: 203-748-5689
  • Fax: 203-790-8183
Mailing address:
  • Phone: 203-748-5689
  • Fax: 203-790-8183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007666
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: