Provider Demographics
NPI:1497762942
Name:TIDWELL, ANGELA AVRETT (SLP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:AVRETT
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72053
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35407-2053
Mailing Address - Country:US
Mailing Address - Phone:205-556-6952
Mailing Address - Fax:
Practice Address - Street 1:700 19TH ST S
Practice Address - Street 2:AUDIOLOGY/SPEECH PATHOLOGY(126)
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1927
Practice Address - Country:US
Practice Address - Phone:205-933-8101
Practice Address - Fax:205-933-4464
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist