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NPI Code Detail

MEDICARE: MR. BENJAMIN L TIDWELL LCSW, CCDP-DIPLOMATE

MEDICARE: MR. BENJAMIN L TIDWELL LCSW, CCDP-DIPLOMATE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker1283CAR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1861407520
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BENJAMIN L TIDWELL LCSW, CCDP-DIPLOMATE
Provider Business Mailing Address
First Line : 35 GOFF ST
Second Line :
City : VILONIA
State : AR
Zip : 72173-9315
Country : US
Telephone Number : 501-580-0116
Fax Number :
Provider Business Practice Location Address
First Line : 5905 US 301 S
Second Line :
City : RIVERVIEW
State : FL
Zip : 33578-3800
Country : US
Telephone Number : 866-389-2727
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/30/2006
Last Update Date : 08/11/2021

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