Healthcare Provider Details

I. General information

NPI: 1831510189
Provider Name (Legal Business Name): BRANDY LEE TIDWELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 SE DUKE ST
PORTLAND OR
97206-6665
US

IV. Provider business mailing address

6536 SE DUKE ST
PORTLAND OR
97206-6665
US

V. Phone/Fax

Practice location:
  • Phone: 503-406-6546
  • Fax: 503-386-3354
Mailing address:
  • Phone: 503-406-6546
  • Fax: 503-386-3354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3798
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: