Provider Demographics
NPI:1831510189
Name:TIDWELL, BRANDY LEE (PHD)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1441
Mailing Address - Country:US
Mailing Address - Phone:503-281-4852
Mailing Address - Fax:
Practice Address - Street 1:3700 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1441
Practice Address - Country:US
Practice Address - Phone:503-281-4852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor