Individual
KHALIA TIDWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
6923 N FESSENDEN ST APT E, PORTLAND, OR 97203-1894
(971) 258-5803
Mailing address
8915 SW CENTER ST, PORTLAND, OR 97223-6307
(503) 726-3690
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
101YM0800X
Mental Health Counselor
—
—
Other
Enumeration date
09/10/2024
Last updated
09/23/2024
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