Provider Demographics
NPI:1902141617
Name:TIDWELL& MILLER COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:TIDWELL& MILLER COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:WARDRETT
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-626-9690
Mailing Address - Street 1:215 CHURCH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3330
Mailing Address - Country:US
Mailing Address - Phone:404-626-9690
Mailing Address - Fax:770-808-9273
Practice Address - Street 1:215 CHURCH ST STE 105
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3330
Practice Address - Country:US
Practice Address - Phone:404-626-9690
Practice Address - Fax:770-808-9273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0006491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1053692848OtherINDIVIDUAL NPI
GA1750602173OtherORGANIZATIONAL NPI
GA003112377AMedicaid