Healthcare Provider Details

I. General information

NPI: 1588816490
Provider Name (Legal Business Name): BRUCE BERNARD TISDALE DSW, LICSW, LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 AUTH ROAD ST 203
SUITLAND MD
20746
US

IV. Provider business mailing address

5805 MCINTOSH PL
BRANDYWINE MD
20613-7795
US

V. Phone/Fax

Practice location:
  • Phone: 202-257-6632
  • Fax:
Mailing address:
  • Phone: 202-257-6632
  • Fax: 202-257-6632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC50078990
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50078990
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberG11619
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: