Healthcare Provider Details

I. General information

NPI: 1205584497
Provider Name (Legal Business Name): DAWN M TISDALE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 LAWN AVE
BUFFALO NY
14207-1816
US

IV. Provider business mailing address

155 LAWN AVE
BUFFALO NY
14207-1816
US

V. Phone/Fax

Practice location:
  • Phone: 716-875-2904
  • Fax: 716-875-6717
Mailing address:
  • Phone: 716-875-2904
  • Fax: 716-875-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number128856-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1964864251
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: