Provider Demographics
NPI:1083622914
Name:TISDALE, ALICIA ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:ELLEN
Last Name:TISDALE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 WILLOW POND DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323
Mailing Address - Country:US
Mailing Address - Phone:248-706-1453
Mailing Address - Fax:
Practice Address - Street 1:5665 W MAPLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3741
Practice Address - Country:US
Practice Address - Phone:248-626-8833
Practice Address - Fax:248-626-8836
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003007103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
620F34900Medicare UPIN
0F34900Medicare ID - Type Unspecified