Provider Demographics
NPI:1821416710
Name:TIDWELL, EVELYN JEAN (M ED, LAT, RMT)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:JEAN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:M ED, LAT, RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 POND VIEW PASS
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-3613
Mailing Address - Country:US
Mailing Address - Phone:210-573-4165
Mailing Address - Fax:
Practice Address - Street 1:319 POND VIEW PASS
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-3613
Practice Address - Country:US
Practice Address - Phone:210-573-4165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT14862255A2300X
TXMT030247225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist