Provider Demographics
NPI:1861407520
Name:TIDWELL, BENJAMIN L (LCSW, CCDP-DIPLOMATE)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:L
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:LCSW, CCDP-DIPLOMATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 GOFF ST
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-9315
Mailing Address - Country:US
Mailing Address - Phone:501-580-0116
Mailing Address - Fax:
Practice Address - Street 1:5905 US 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3800
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1283C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175962795Medicaid
AR175962795Medicaid