Healthcare Provider Details

I. General information

NPI: 1255658944
Provider Name (Legal Business Name): SHELBY O TIDWELL BA, PSRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARLINGTON ST STE G
ADA OK
74820-4072
US

IV. Provider business mailing address

1201 ARLINGTON ST STE G
ADA OK
74820-4072
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-6851
  • Fax: 580-310-6047
Mailing address:
  • Phone: 580-332-6851
  • Fax: 580-310-6047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: