Provider Demographics
NPI:1871661074
Name:TIDWELL, DERRELL R (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DERRELL
Middle Name:R
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:310-871-2954
Mailing Address - Fax:
Practice Address - Street 1:432 30TH STREET
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368
Practice Address - Country:US
Practice Address - Phone:310-670-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical