Provider Demographics
NPI:1114501863
Name:TYDINGS, LORI ANN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:TYDINGS
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 1:2414 S IMO RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-7209
Mailing Address - Country:US
Mailing Address - Phone:580-554-9791
Mailing Address - Fax:
Practice Address - Street 1:2102 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-7654
Practice Address - Country:US
Practice Address - Phone:580-366-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2080Medicaid