Provider Demographics
NPI:1265856769
Name:TIDWELL, MCKENZIE S (LPC)
Entity Type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:S
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:MCKENZIE
Other - Middle Name:S
Other - Last Name:FALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081
Mailing Address - Country:US
Mailing Address - Phone:334-566-6022
Mailing Address - Fax:334-566-5346
Practice Address - Street 1:200 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081
Practice Address - Country:US
Practice Address - Phone:334-566-6022
Practice Address - Fax:334-566-5346
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2219A101YM0800X
AL3494101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health