Provider Demographics
NPI:1124476858
Name:TIDWELL SOCIAL WORK SERVICES AND CONSULTING, INC.
Entity type:Organization
Organization Name:TIDWELL SOCIAL WORK SERVICES AND CONSULTING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:MATLOCK
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-853-6649
Mailing Address - Street 1:7285 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0926
Mailing Address - Country:US
Mailing Address - Phone:208-853-5095
Mailing Address - Fax:208-853-5125
Practice Address - Street 1:5999 W. STATE ST.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-853-5095
Practice Address - Fax:208-853-5125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6143251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health