Provider Demographics
NPI:1770729998
Name:TIDWELL, ANGELA KIM (SLP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:KIM
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:HESTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:147 PECAN HILL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5233
Mailing Address - Country:US
Mailing Address - Phone:601-862-9265
Mailing Address - Fax:
Practice Address - Street 1:733 N. FLAG CHAPEL ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209
Practice Address - Country:US
Practice Address - Phone:601-922-5530
Practice Address - Fax:601-922-5534
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS2357OtherMS STATE BOARD OF HEALTH