Provider Demographics
NPI:1508572769
Name:TIDWELL, ZACKARY JAMES (BA)
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:JAMES
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 19TH ST APT 3017
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-6067
Mailing Address - Country:US
Mailing Address - Phone:703-989-0488
Mailing Address - Fax:
Practice Address - Street 1:10650 E BETHANY DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-2653
Practice Address - Country:US
Practice Address - Phone:720-584-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician