Healthcare Provider Details

I. General information

NPI: 1861793085
Provider Name (Legal Business Name): MARY M TIDYMAN PLMHP, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N BAILEY
NORTH PLATTE NE
69101
US

IV. Provider business mailing address

110 N BAILEY P.O. BOX 1208
NORTH PLATTE NE
69103-1208
US

V. Phone/Fax

Practice location:
  • Phone: 308-534-6029
  • Fax: 308-534-6961
Mailing address:
  • Phone: 308-534-6029
  • Fax: 308-534-6961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1280
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14180
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: