Provider Demographics
NPI:1861917551
Name:TIDD, SKYLER (DPT)
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:
Last Name:TIDD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 LAKE CASCADE PKWY
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-7702
Mailing Address - Country:US
Mailing Address - Phone:208-382-3862
Mailing Address - Fax:
Practice Address - Street 1:402 LAKE CASCADE PARKWAY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611
Practice Address - Country:US
Practice Address - Phone:208-382-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist