Kenneth Dorsey Tisdale, L.C.I.C.I., LMT #548

Primary specialty

ContractorTaxonomy code 171W00000X

License

LMT # 5488 Issued in NM

Practice address

201 Eubank Blvd NE
B1
Albuquerque, NM 87123

Phone

(505) 712-7585

NPI assigned

Feb 28, 2011

Last updated

Feb 28, 2011By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1298851200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1298851200000",
    "number": "1962709956",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8400 MENAUL BLVD",
            "address_2": "8400 MENAUL BLVD. NE. #217",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "87112",
            "telephone_number": "505-712-7585"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "201 EUBANK BLVD NE",
            "address_2": "B1",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "87123",
            "telephone_number": "505-712-7585"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TISDALE",
        "first_name": "KENNETH",
        "middle_name": "DORSEY",
        "credential": "L.C.I.C.I., LMT #548",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2011-02-28",
        "last_updated": "2011-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171W00000X",
            "taxonomy_group": "",
            "desc": "Contractor",
            "state": "NM",
            "license": "LMT # 5488",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Angelique Tippner
• Faith Myranda Tipton, LCSW
• Mariantonieta Tirado Gonzalez, M.D.
• Martha Tiryaki, CNM
• Angela Tisdale
• Steven Tise
• Pauline Tither, CNP
• Barbara R Tiwald, RN, BSN
• Heather Tkaczyk
• TLC Assisted Living (Aldea House)

• Contractor in Albuquerque, NM
• Providers in Albuquerque, NM by specialty
• Contractor in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.