Provider Demographics
NPI:1083767131
Name:TIDWELL, KATHY MATLOCK (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:MATLOCK
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7285 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0926
Mailing Address - Country:US
Mailing Address - Phone:208-853-5095
Mailing Address - Fax:208-853-5125
Practice Address - Street 1:5999 W STATE ST STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3039
Practice Address - Country:US
Practice Address - Phone:208-853-5095
Practice Address - Fax:208-853-5125
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 8581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical