Provider Demographics
NPI:1255658944
Name:TIDWELL, SHELBY O (BA, PSRS)
Entity Type:Individual
Prefix:MR
First Name:SHELBY
Middle Name:O
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:BA, PSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 ARLINGTON ST STE G
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4072
Mailing Address - Country:US
Mailing Address - Phone:580-332-6851
Mailing Address - Fax:580-310-6047
Practice Address - Street 1:1201 ARLINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4072
Practice Address - Country:US
Practice Address - Phone:580-332-6851
Practice Address - Fax:580-310-6047
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health