Provider Demographics
NPI:1417508870
Name:TIDMORE, DANIELLE NICOLE (LISW)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:NICOLE
Last Name:TIDMORE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 TUSKEGEE AIRMEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311
Mailing Address - Country:US
Mailing Address - Phone:940-676-6075
Mailing Address - Fax:
Practice Address - Street 1:527 TUSKEGEE AIRMEN AVENUE
Practice Address - Street 2:
Practice Address - City:SHEPPARD AIR FORCE BASE
Practice Address - State:TX
Practice Address - Zip Code:76311-6437
Practice Address - Country:US
Practice Address - Phone:405-940-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1208491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical