Provider Demographics
NPI:1629607619
Name:TIDBALL, ELEANOR ARLENE (LPC-IT)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:ARLENE
Last Name:TIDBALL
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13320 W GRANGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-8131
Mailing Address - Country:US
Mailing Address - Phone:414-467-3780
Mailing Address - Fax:
Practice Address - Street 1:13320 W GRANGE AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-8131
Practice Address - Country:US
Practice Address - Phone:414-467-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4590-226103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19943852Medicaid