Provider Demographics
NPI:1730756800
Name:TIDWELL, OWEN (LICSW)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 DRIFT RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-1235
Mailing Address - Country:US
Mailing Address - Phone:508-493-5518
Mailing Address - Fax:
Practice Address - Street 1:126 COVE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-1357
Practice Address - Country:US
Practice Address - Phone:508-324-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224258101Y00000X
MA124273101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor