Provider Demographics
NPI:1376976514
Name:TIDWELL, LINDSEY C (MS, LMSW)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:C
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:MS, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 BAY AREA BLVD
Mailing Address - Street 2:118
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2627
Mailing Address - Country:US
Mailing Address - Phone:832-224-4490
Mailing Address - Fax:
Practice Address - Street 1:1020 BAY AREA BLVD
Practice Address - Street 2:118
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2627
Practice Address - Country:US
Practice Address - Phone:832-224-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58147101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1407841299Medicaid