Provider Demographics
NPI:1588816490
Name:TISDALE, BRUCE BERNARD (DSW, LICSW, LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:BERNARD
Last Name:TISDALE
Suffix:
Gender:M
Credentials:DSW, LICSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 MCINTOSH PL
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-7795
Mailing Address - Country:US
Mailing Address - Phone:202-257-6632
Mailing Address - Fax:202-257-6632
Practice Address - Street 1:5211 AUTH ROAD ST 203
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746
Practice Address - Country:US
Practice Address - Phone:202-257-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC50078990101YM0800X
104100000X, 261QD1600X
MDLC500789901041C0700X
MDG116191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD$$$$$$$$$Medicaid