Provider Demographics
NPI:1588919856
Name:TIDWELL, TRAVIS MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:MATTHEW
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2587 COMMONS BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3841
Mailing Address - Country:US
Mailing Address - Phone:937-426-5555
Mailing Address - Fax:937-426-5556
Practice Address - Street 1:2587 COMMONS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3841
Practice Address - Country:US
Practice Address - Phone:937-426-5555
Practice Address - Fax:937-426-5556
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60290874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist