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General NPI Number Information
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NPI Number | 1902141617
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Entity Type | Organization
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Legal Business Name | TIDWELL& MILLER COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 12/06/2012
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Last Update Date | 12/06/2012
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Provider Practice Location Address
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Address Line | 215 CHURCH ST STE 105
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City | DECATUR
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State | GA
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Zip | 30030-3330
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Country | US
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Telephone | 404-626-9690
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Fax | 770-808-9273
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Provider Business Mailing Address
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Address Line | 215 CHURCH ST STE 105
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City | DECATUR
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State | GA
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Zip | 30030-3330
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Country | US
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Telephone | 404-626-9690
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Fax | 770-808-9273
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | MS. PHYLLIS WARDRETT MILLER
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Credential | LCSW
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Telephone | 404-626-9690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW000649
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License Number State | GA
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