Provider Demographics
NPI:1043331473
Name:TWEEDDALE, JOANN INGLUT (LICSW)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:INGLUT
Last Name:TWEEDDALE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25818-0914
Mailing Address - Country:US
Mailing Address - Phone:304-573-1523
Mailing Address - Fax:
Practice Address - Street 1:100 2ND AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1015
Practice Address - Country:US
Practice Address - Phone:304-573-1523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043491041C0700X
WVDP009433501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDP00943350OtherLICENSE
NC6003016Medicaid