Provider Demographics
NPI:1003250754
Name:TIDWELL, CAROL (MS LCPC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S LINDER RD APT A308
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4421
Mailing Address - Country:US
Mailing Address - Phone:208-794-9502
Mailing Address - Fax:
Practice Address - Street 1:225 S LINDER RD APT A308
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4421
Practice Address - Country:US
Practice Address - Phone:208-546-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-5223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health