Active NPI
Derrell R. Tidwell, LCSW
- Clinical Social Worker
- Port Townsend, WA
National Provider Identifier
1871661074
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 9609
- Practice address
- 432 30TH Street
Port Townsend, WA 98368 - Phone
- (310) 670-4295
- NPI assigned
- Dec 4, 2006
- Sex
- Male
- 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 |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 9609 | CA | Primary |
Addresses
Primary practice location
432 30TH Street
Port Townsend, WA 98368
Mailing address
432 30TH Street
Port Townsend, WA 98368
Phone (310) 871-2954
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 |
|---|---|---|---|
| 9609 | CA | MD | Addiction (Substance Use Disorder) Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1165190400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1707868800000",
"number": "1871661074",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "432 30TH STREET",
"city": "PORT TOWNSEND",
"state": "WA",
"postal_code": "98368",
"telephone_number": "310-871-2954"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "432 30TH STREET",
"city": "PORT TOWNSEND",
"state": "WA",
"postal_code": "98368",
"telephone_number": "310-670-4295"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TIDWELL",
"first_name": "DERRELL",
"middle_name": "R.",
"name_prefix": "Mr.",
"credential": "LCSW",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-04",
"last_updated": "2024-02-14",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "CA",
"license": "9609",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Port Townsend, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.