Provider Demographics
NPI:1437713039
Name:TIDWELL, COURTNEY (LPC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
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 1:820 ABBERLY DR APT 104
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6562
Mailing Address - Country:US
Mailing Address - Phone:703-927-1684
Mailing Address - Fax:
Practice Address - Street 1:510 PRINCESS ANNE ST STE 101
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-6077
Practice Address - Country:US
Practice Address - Phone:540-693-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006751101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional