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General NPI Number Information
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NPI Number | 1003250754
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Entity Type | Individual
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Provider Name | CAROL TIDWELL MS. LCPC
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Gender | Female
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Dates
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Enumeration Date | 04/24/2013
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Last Update Date | 06/05/2023
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Provider Practice Location Address
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Address Line | 225 S LINDER RD APT A308
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City | EAGLE
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State | ID
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Zip | 83616-4421
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Country | US
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Telephone | 208-546-1808
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Fax |
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Provider Business Mailing Address
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Address Line | 225 S LINDER RD APT A308
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City | EAGLE
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State | ID
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Zip | 83616-4421
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Country | US
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Telephone | 208-794-9502
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC-5223
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License Number State | ID
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