Healthcare Provider Details

I. General information

NPI: 1437713039
Provider Name (Legal Business Name): COURTNEY TIDWELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 PRINCESS ANNE ST STE 101
FREDERICKSBURG VA
22401-6077
US

IV. Provider business mailing address

820 ABBERLY DR APT 104
STAFFORD VA
22554-6562
US

V. Phone/Fax

Practice location:
  • Phone: 540-693-0096
  • Fax:
Mailing address:
  • Phone: 703-927-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006751
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: