Provider Demographics
NPI:1730631359
Name:TIDWELL, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19631 CLIFTON WAY
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1280 IROQUOIS AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8551
Practice Address - Country:US
Practice Address - Phone:630-229-8843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst