Provider Demographics
NPI:1518949312
Name:TIDWELL, HENRY CLAY (LMSW-CSW)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:CLAY
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:LMSW-CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1350
Mailing Address - Country:US
Mailing Address - Phone:810-667-5500
Mailing Address - Fax:
Practice Address - Street 1:1375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1350
Practice Address - Country:US
Practice Address - Phone:810-667-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010709861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical