Basic Information
| Provider Information | |||||||||
| NPI: | 1255658944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIDWELL | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA, PSRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 ARLINGTON ST STE G | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803326851 | ||||||||
| FaxNumber: | 5803106047 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 ARLINGTON ST STE G | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803326851 | ||||||||
| FaxNumber: | 5803106047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.