Provider Demographics
NPI:1609213446
Name:TIDWELL, LORISA DAWN (LCSW)
Entity type:Individual
Prefix:
First Name:LORISA
Middle Name:DAWN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 CUMBERLAND LN
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7568
Mailing Address - Country:US
Mailing Address - Phone:405-693-6061
Mailing Address - Fax:
Practice Address - Street 1:2632 LYNN LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-1702
Practice Address - Country:US
Practice Address - Phone:402-366-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical