Provider Demographics
NPI:1063117976
Name:TISDALE, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TISDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 GALLATIN ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-6918
Mailing Address - Country:US
Mailing Address - Phone:202-621-4239
Mailing Address - Fax:
Practice Address - Street 1:4660 MARTIN LUTHER KING JR AVE SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4933
Practice Address - Country:US
Practice Address - Phone:202-318-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor