Provider Demographics
NPI:1871093922
Name:TISDALE, ASHTON DOBY (LISW-CP, LAC, AADC)
Entity type:Individual
Prefix:
First Name:ASHTON
Middle Name:DOBY
Last Name:TISDALE
Suffix:
Gender:F
Credentials:LISW-CP, LAC, AADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 HEINS RD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8922
Mailing Address - Country:US
Mailing Address - Phone:803-875-1699
Mailing Address - Fax:803-728-3047
Practice Address - Street 1:1224 PICKENS ST STE 220
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3428
Practice Address - Country:US
Practice Address - Phone:803-875-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10820101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)