Provider Demographics
NPI:1083209118
Name:TIDWELL, ASHLEY B
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:B
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2586
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-2586
Mailing Address - Country:US
Mailing Address - Phone:503-806-6966
Mailing Address - Fax:
Practice Address - Street 1:14344 SE BRIDGETON ST
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6265
Practice Address - Country:US
Practice Address - Phone:503-806-6966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health