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 1:6536 SE DUKE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6665
Mailing Address - Country:US
Mailing Address - Phone:503-406-6546
Mailing Address - Fax:503-386-3354
Practice Address - Street 1:6536 SE DUKE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6665
Practice Address - Country:US
Practice Address - Phone:503-406-6546
Practice Address - Fax:503-386-3354
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3798103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical