Provider Demographics
NPI:1760024020
Name:TIDWELL-BASHAM, CASSONDRA JADE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:CASSONDRA
Middle Name:JADE
Last Name:TIDWELL-BASHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CASSONDRA
Other - Middle Name:JADE
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-336-1339
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-336-1339
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker