Provider Demographics
NPI:1104564053
Name:TIDWELL, CINNAMON
Entity type:Individual
Prefix:
First Name:CINNAMON
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CINNAMON
Other - Middle Name:
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3502 COUNTY ROAD 42.2
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-9131
Mailing Address - Country:US
Mailing Address - Phone:970-485-4942
Mailing Address - Fax:
Practice Address - Street 1:3502 COUNTY ROAD 42.2
Practice Address - Street 2:
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-9131
Practice Address - Country:US
Practice Address - Phone:970-485-4942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health