Provider Demographics
NPI:1689793226
Name:TIDD, JEFF THOMAL (LCPC)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:THOMAL
Last Name:TIDD
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2239
Mailing Address - Country:US
Mailing Address - Phone:207-321-8828
Mailing Address - Fax:
Practice Address - Street 1:86 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4808
Practice Address - Country:US
Practice Address - Phone:207-321-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health