Provider Demographics
NPI:1467547497
Name:TIDWELL, CYNTHIA A (LICSW)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:A
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 AMHERST STREET
Mailing Address - Street 2:WILLOWDALE COUNSELING CENTER, PLLC
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063
Mailing Address - Country:US
Mailing Address - Phone:603-881-7554
Mailing Address - Fax:603-881-7533
Practice Address - Street 1:322 AMHERST STREET
Practice Address - Street 2:WILLOWDALE COUNSELING CENTER, PLLC
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063
Practice Address - Country:US
Practice Address - Phone:603-881-7554
Practice Address - Fax:603-881-7533
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4391041C0700X
NH#439104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30421869Medicaid