Provider Demographics
NPI:1528510658
Name:TIDWELL, CHRISTEN (PTA)
Entity type:Individual
Prefix:
First Name:CHRISTEN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3784 N JOT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5770
Mailing Address - Country:US
Mailing Address - Phone:615-715-3612
Mailing Address - Fax:
Practice Address - Street 1:3452 LAKE LYNDA DR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1481
Practice Address - Country:US
Practice Address - Phone:800-774-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6188208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation