Provider Demographics
NPI:1235421678
Name:TISDALE-MCINTOSH, SYLVIA D
Entity Type:Individual
Prefix:MRS
First Name:SYLVIA
Middle Name:D
Last Name:TISDALE-MCINTOSH
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 1:1717 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3124
Mailing Address - Country:US
Mailing Address - Phone:662-680-4870
Mailing Address - Fax:662-680-4871
Practice Address - Street 1:1717 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3124
Practice Address - Country:US
Practice Address - Phone:662-680-4870
Practice Address - Fax:662-680-4871
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health