Provider Demographics
NPI:1992935142
Name:TIDWELL, STEWART GREGORY (MA, LMHC)
Entity type:Individual
Prefix:MR
First Name:STEWART
Middle Name:GREGORY
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5407
Mailing Address - Country:US
Mailing Address - Phone:260-484-4153
Mailing Address - Fax:
Practice Address - Street 1:2525 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5407
Practice Address - Country:US
Practice Address - Phone:260-484-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001806A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health