Provider Demographics
NPI:1609647627
Name:TIDWELL, KRISTINA JOAN (APCC)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:JOAN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31189 MOUNTAIN LILAC WAY
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4177
Mailing Address - Country:US
Mailing Address - Phone:909-708-5106
Mailing Address - Fax:
Practice Address - Street 1:41680 IVY ST STE D
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9435
Practice Address - Country:US
Practice Address - Phone:619-549-0329
Practice Address - Fax:619-550-3547
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health