Provider Demographics
NPI:1518289198
Name:TISDALE, CASEY RENAE
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:RENAE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 HIGHLAND PARK
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:850-443-8577
Mailing Address - Fax:
Practice Address - Street 1:1616 S. SPRING ST.
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206
Practice Address - Country:US
Practice Address - Phone:205-942-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2753235Z00000X
12083868ASHA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist