Provider Demographics
NPI:1386005650
Name:TISDALE, SETH (MS,ATC, LAT,CES)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:TISDALE
Suffix:
Gender:M
Credentials:MS,ATC, LAT,CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 W NEW YORK AVE
Mailing Address - Street 2:APT. D
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-5349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:421 N WOODLAND BLVD
Practice Address - Street 2:UNIT 8284
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-8300
Practice Address - Country:US
Practice Address - Phone:386-822-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer