Active NPI
Eleanor Arlene Tidball, LPC-IT
- Counseling Psychologist
- New Berlin, WI
National Provider Identifier
1629607619
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counseling Psychologist
- License
- 4590-226
- Practice address
- 13320 W Grange Ave
New Berlin, WI 53151-8131 - Phone
- (414) 467-3780
- NPI assigned
- Apr 2, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counseling Psychologist | 103TC1900X | 4590-226 | WI | Primary |
Addresses
Primary practice location
13320 W Grange Ave
New Berlin, WI 53151-8131
Mailing address
13320 W Grange Ave
New Berlin, WI 53151-8131
Phone (414) 467-3780
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 19943852 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4590-226 | WI | MD | Counseling Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1585785600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1585785600000",
"number": "1629607619",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13320 W GRANGE AVE",
"city": "NEW BERLIN",
"state": "WI",
"postal_code": "531518131",
"telephone_number": "414-467-3780"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "13320 W GRANGE AVE",
"city": "NEW BERLIN",
"state": "WI",
"postal_code": "531518131",
"telephone_number": "414-467-3780"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIDBALL",
"first_name": "ELEANOR",
"middle_name": "ARLENE",
"credential": "LPC-IT",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-04-02",
"last_updated": "2020-04-02",
"certification_date": "2020-04-02",
"status": "A"
},
"taxonomies": [
{
"code": "103TC1900X",
"taxonomy_group": "",
"desc": "Psychologist, Counseling",
"state": "WI",
"license": "4590-226",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "19943852",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in New Berlin, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.