Provider Demographics
NPI:1790276996
Name:TIDWELL, TERI
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:TIDWELL
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 1:4742 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MI
Mailing Address - Zip Code:48611-8514
Mailing Address - Country:US
Mailing Address - Phone:810-278-4599
Mailing Address - Fax:
Practice Address - Street 1:4401 CAMPUS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6112
Practice Address - Country:US
Practice Address - Phone:989-837-9100
Practice Address - Fax:989-837-9105
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist