Provider Demographics
NPI:1669401311
Name:KATHY MATLOCK TIDWELL
Entity type:Organization
Organization Name:KATHY MATLOCK TIDWELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
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:2006-07-02
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806014000Medicaid
ID806014000Medicaid