Provider Demographics
NPI:1063901668
Name:TIDWELL, ANGELA MARY (OT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARY
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 STAMFORD CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-7042
Mailing Address - Country:US
Mailing Address - Phone:407-766-8747
Mailing Address - Fax:
Practice Address - Street 1:136 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6959
Practice Address - Country:US
Practice Address - Phone:704-360-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8534225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand