Provider Demographics
NPI:1366957011
Name:TISDALE, EMILY JANE (BCBA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JANE
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1203 US HIGHWAY 98 STE 2A9
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-3901
Mailing Address - Country:US
Mailing Address - Phone:314-920-1828
Mailing Address - Fax:251-243-0984
Practice Address - Street 1:1203 US HIGHWAY 98 STE 2A9
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526
Practice Address - Country:US
Practice Address - Phone:314-920-1828
Practice Address - Fax:251-243-0984
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0-14-6203103K00000X
AL1-18-33094103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst