Provider Demographics
NPI:1396046306
Name:TIDWELL, MARYANN (LMT)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 N LOS ALTOS DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2135
Mailing Address - Country:US
Mailing Address - Phone:602-743-4263
Mailing Address - Fax:
Practice Address - Street 1:930 W WARNER RD
Practice Address - Street 2:SUITE 32
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1040
Practice Address - Country:US
Practice Address - Phone:602-743-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-07
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10661225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist