Healthcare Provider Details

I. General information

NPI: 1629607619
Provider Name (Legal Business Name): ELEANOR ARLENE TIDBALL LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13320 W GRANGE AVE
NEW BERLIN WI
53151-8131
US

IV. Provider business mailing address

13320 W GRANGE AVE
NEW BERLIN WI
53151-8131
US

V. Phone/Fax

Practice location:
  • Phone: 414-467-3780
  • Fax:
Mailing address:
  • Phone: 414-467-3780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4590-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: