Provider Demographics
NPI:1316450976
Name:TIDWELL, PATRICK R (PHD, LMFT)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3884 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-1641
Mailing Address - Country:US
Mailing Address - Phone:334-787-0601
Mailing Address - Fax:
Practice Address - Street 1:1425 I-65 PARKWAY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2860
Practice Address - Country:US
Practice Address - Phone:404-989-2867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251S00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL251S00000XMedicaid