Provider Demographics
NPI:1235162553
Name:TISDALE, SHAWNTA' TYRRELL
Entity Type:Individual
Prefix:
First Name:SHAWNTA'
Middle Name:TYRRELL
Last Name:TISDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1184 SUMTER HWY
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4951
Mailing Address - Country:US
Mailing Address - Phone:843-382-3867
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor