Healthcare Provider Details

I. General information

NPI: 1902141617
Provider Name (Legal Business Name): TIDWELL& MILLER COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 CHURCH ST STE 105
DECATUR GA
30030-3330
US

IV. Provider business mailing address

215 CHURCH ST STE 105
DECATUR GA
30030-3330
US

V. Phone/Fax

Practice location:
  • Phone: 404-626-9690
  • Fax: 770-808-9273
Mailing address:
  • Phone: 404-626-9690
  • Fax: 770-808-9273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW000649
License Number StateGA

VIII. Authorized Official

Name: MS. PHYLLIS WARDRETT MILLER
Title or Position: MANAGING PARTNER
Credential: LCSW
Phone: 404-626-9690