| Doctor Name: | SHAWNTA' TYRRELL TISDALE |
| NPI Number: | 1235162553 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 164 Waccamaw Medical Park Dr Conway, SC - 295268903 |
| Business Phone Number: | 8433475060 |
| Business Fax Number: | |
| Mailing Address: | 1184 Sumter Hwy, KINGSTREE |
| State: | SC |
| Postal Code: | 295564951 |
| Phone Number: | 8433823867 |
| Fax Number: | |
| NPI Enumeration Date: | 07/09/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |