Provider Demographics
NPI:1275695165
Name:TIDSWORTH, MARK E (MED)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:TIDSWORTH
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7651
Mailing Address - Country:US
Mailing Address - Phone:803-808-9623
Mailing Address - Fax:
Practice Address - Street 1:1431 N LAKE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7651
Practice Address - Country:US
Practice Address - Phone:803-808-9623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional