Provider Demographics
NPI:1932704459
Name:TILDEN, MICHAEL BENNETT (LCSW, CTRS, AMGA-SPI)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BENNETT
Last Name:TILDEN
Suffix:
Gender:M
Credentials:LCSW, CTRS, AMGA-SPI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 GREGORY LN # 4
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9021
Mailing Address - Country:US
Mailing Address - Phone:307-734-6040
Mailing Address - Fax:
Practice Address - Street 1:1490 GREGORY LN # 4
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9021
Practice Address - Country:US
Practice Address - Phone:307-734-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-401461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical