Provider Demographics
NPI:1912568726
Name:TIDEY, KENDALL LEE (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:LEE
Last Name:TIDEY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 TIMBER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7466
Mailing Address - Country:US
Mailing Address - Phone:910-990-9225
Mailing Address - Fax:
Practice Address - Street 1:3001 WRIGHTSVILLE AVE STE B
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4106
Practice Address - Country:US
Practice Address - Phone:910-526-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0137451041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical