Provider Demographics
NPI:1659623833
Name:TIDWELL, TONYA (LAC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:
Other - Last Name:MCFARLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35 GOFF ST
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-9315
Mailing Address - Country:US
Mailing Address - Phone:479-567-1858
Mailing Address - Fax:
Practice Address - Street 1:800 EXCHANGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7833
Practice Address - Country:US
Practice Address - Phone:501-781-2230
Practice Address - Fax:870-972-4911
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARA2205009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator