Healthcare Provider Details

I. General information

NPI: 1871661074
Provider Name (Legal Business Name): DERRELL R. TIDWELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 02/14/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 30TH STREET
PORT TOWNSEND WA
98368
US

IV. Provider business mailing address

432 30TH STREET
PORT TOWNSEND WA
98368
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-4295
  • Fax:
Mailing address:
  • Phone: 310-871-2954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: