Healthcare Provider Details

I. General information

NPI: 1629375761
Provider Name (Legal Business Name): LISA D TIDWELL-MCKAY MS, CADC, LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

6810 S. 55TH ST. E.
MUSKOGEE OK
74403
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-3555
  • Fax: 539-234-3501
Mailing address:
  • Phone: 918-310-6279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number412
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5739
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: