Provider Demographics
NPI:1235146424
Name:NIDEVER, TAMMY S (LCDC)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:S
Last Name:NIDEVER
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 JUNCTION HWY STE E
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5075
Mailing Address - Country:US
Mailing Address - Phone:830-257-8585
Mailing Address - Fax:830-257-8585
Practice Address - Street 1:604 JUNCTION HWY STE E
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5075
Practice Address - Country:US
Practice Address - Phone:830-257-8585
Practice Address - Fax:830-257-8585
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8065101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health