Provider Demographics
NPI:1760891063
Name:TIDWELL SOCIAL WORK SERVICES AND CONSULTING, INC.
Entity Type:Organization
Organization Name:TIDWELL SOCIAL WORK SERVICES AND CONSULTING, INC.
Other - Org Name:TIDWELL SOCIAL WORK SERVICES AND CONSULTING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-853-5095
Mailing Address - Street 1:5999 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5059
Mailing Address - Country:US
Mailing Address - Phone:208-853-5095
Mailing Address - Fax:208-853-5125
Practice Address - Street 1:5999 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5059
Practice Address - Country:US
Practice Address - Phone:208-853-5095
Practice Address - Fax:208-853-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty