Provider Demographics
NPI:1407473234
Name:TIDWELL, MARY C (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BOSTON AVE STE 500-5
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74103-4016
Mailing Address - Country:US
Mailing Address - Phone:918-641-4750
Mailing Address - Fax:
Practice Address - Street 1:401 S BOSTON AVE STE 500-5
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-4016
Practice Address - Country:US
Practice Address - Phone:918-641-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-27
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK10926101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health