Provider Demographics
NPI:1790189413
Name:TIDWELL, STACEY (LCSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 MORADA LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-3148
Mailing Address - Country:US
Mailing Address - Phone:209-647-3047
Mailing Address - Fax:
Practice Address - Street 1:3311 MORADA LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-3148
Practice Address - Country:US
Practice Address - Phone:209-647-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool