Provider Demographics
NPI:1114119039
Name:TISDALE, JOHN K (DMIN)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:TISDALE
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLOISTER CT
Mailing Address - Street 2:SUITE F
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2207
Mailing Address - Country:US
Mailing Address - Phone:919-408-3212
Mailing Address - Fax:919-408-3306
Practice Address - Street 1:101 CLOISTER CT
Practice Address - Street 2:SUITE F
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2207
Practice Address - Country:US
Practice Address - Phone:919-408-3212
Practice Address - Fax:919-408-3306
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2496101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional