Provider Demographics
NPI:1306559380
Name:TISDALE, HERBERT TAYLOR III (SOCIAL WORKER)
Entity type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:TAYLOR
Last Name:TISDALE
Suffix:III
Gender:M
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 PARADISO DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-1644
Mailing Address - Country:US
Mailing Address - Phone:251-455-4745
Mailing Address - Fax:813-475-5278
Practice Address - Street 1:2814 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5471
Practice Address - Country:US
Practice Address - Phone:813-653-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW202281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical