Provider Demographics
NPI: | 1467547497 |
---|---|
Name: | TIDWELL, CYNTHIA A (LICSW) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | CYNTHIA |
Middle Name: | A |
Last Name: | TIDWELL |
Suffix: | |
Gender: | F |
Credentials: | LICSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 322 AMHERST STREET |
Mailing Address - Street 2: | WILLOWDALE COUNSELING CENTER, PLLC |
Mailing Address - City: | NASHUA |
Mailing Address - State: | NH |
Mailing Address - Zip Code: | 03063 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 603-881-7554 |
Mailing Address - Fax: | 603-881-7533 |
Practice Address - Street 1: | 322 AMHERST STREET |
Practice Address - Street 2: | WILLOWDALE COUNSELING CENTER, PLLC |
Practice Address - City: | NASHUA |
Practice Address - State: | NH |
Practice Address - Zip Code: | 03063 |
Practice Address - Country: | US |
Practice Address - Phone: | 603-881-7554 |
Practice Address - Fax: | 603-881-7533 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-04 |
Last Update Date: | 2009-06-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NH | 439 | 1041C0700X |
NH | #439 | 104100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 104100000X | Behavioral Health & Social Service Providers | Social Worker | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NH | 30421869 | Medicaid |