MEDICARE: ELIZABETH TISDALE CPM, LM

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
1	374J00000X	Doula
2	176B00000X	Midwife	99330	TX

General Provider Information

NPI Number	:	1861982928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH TISDALE CPM, LM

Provider Business Mailing Address
First Line	:	1009 CHESTNUT ST
Second Line	:
City	:	BASTROP
State	:	TX
Zip	:	78602-3303
Country	:	US
Telephone Number	:	512-710-9662
Fax Number	:	915-232-9611

Provider Business Practice Location Address
First Line	:	1009 CHESTNUT ST
Second Line	:
City	:	BASTROP
State	:	TX
Zip	:	78602-3303
Country	:	US
Telephone Number	:	512-710-9662
Fax Number	:	915-232-9611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	01/26/2026

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