Provider Demographics
NPI:1699034561
Name:TIDWELL, TROLONDIA ELIZABETH
Entity Type:Individual
Prefix:
First Name:TROLONDIA
Middle Name:ELIZABETH
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DA
Mailing Address - Street 1:1336 NW 105TH
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114
Mailing Address - Country:US
Mailing Address - Phone:405-889-0407
Mailing Address - Fax:
Practice Address - Street 1:1336 NW 100TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-4912
Practice Address - Country:US
Practice Address - Phone:405-889-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker