Provider Demographics
NPI:1407682362
Name:TIDMORE, ANNA GRACE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:TIDMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 DOVE CV
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-7640
Mailing Address - Country:US
Mailing Address - Phone:662-545-1006
Mailing Address - Fax:
Practice Address - Street 1:5960 GETWELL RD STE 212D
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7320
Practice Address - Country:US
Practice Address - Phone:662-228-0130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS5240235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist