Provider Demographics
NPI:1568810315
Name:TIDZUMP, DELANE
Entity Type:Individual
Prefix:
First Name:DELANE
Middle Name:
Last Name:TIDZUMP
Suffix:
Gender:F
Credentials:
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 538
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0538
Mailing Address - Country:US
Mailing Address - Phone:307-335-1169
Mailing Address - Fax:307-335-1170
Practice Address - Street 1:#7 SHIPTON LANE
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0538
Practice Address - Country:US
Practice Address - Phone:307-335-1169
Practice Address - Fax:307-335-1170
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist