Provider Demographics
NPI:1225435993
Name:TIDWELL, PAMELA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ED TODD CT
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-7742
Mailing Address - Country:US
Mailing Address - Phone:615-566-7543
Mailing Address - Fax:
Practice Address - Street 1:205 ED TODD CT
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-7742
Practice Address - Country:US
Practice Address - Phone:615-566-7543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant