Provider Demographics
NPI:1629375761
Name:TIDWELL-MCKAY, LISA D (MS, CADC, LPC-S)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:TIDWELL-MCKAY
Suffix:
Gender:F
Credentials:MS, CADC, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 S. 55TH ST. E.
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403
Mailing Address - Country:US
Mailing Address - Phone:918-310-6279
Mailing Address - Fax:
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-3555
Practice Address - Fax:539-234-3501
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK412101YA0400X
OK5739101YM0800X
OK23834171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator