Provider Demographics
NPI:1346373602
Name:TIDWELL, LORENA ELIZABETH (ATC)
Entity Type:Individual
Prefix:MRS
First Name:LORENA
Middle Name:ELIZABETH
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:ATC
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Mailing Address - Street 1:P140 FORT MCINTOSH
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78040-4344
Mailing Address - Country:US
Mailing Address - Phone:956-723-1153
Mailing Address - Fax:956-721-5877
Practice Address - Street 1:WEST END WASHINTON
Practice Address - Street 2:LAREDO COMMUNITY COLLEGE - ATHLETIC DEPARTMENT
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040
Practice Address - Country:US
Practice Address - Phone:956-721-5326
Practice Address - Fax:956-721-5877
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAT28822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer