Provider Demographics
NPI:1851843437
Name:TISDALE, GLEN EDWARD (LPC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:EDWARD
Last Name:TISDALE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 VALLEYFIELD ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3714
Mailing Address - Country:US
Mailing Address - Phone:210-709-5848
Mailing Address - Fax:
Practice Address - Street 1:4243 E PIEDRAS DR STE 226
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1407
Practice Address - Country:US
Practice Address - Phone:210-709-5848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73414101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional