Provider Demographics
NPI:1821614934
Name:TIDABACK, KATHRYN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:TIDABACK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 BROMMER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2807
Mailing Address - Country:US
Mailing Address - Phone:520-780-0666
Mailing Address - Fax:
Practice Address - Street 1:820 BAY AVE STE 212
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2103
Practice Address - Country:US
Practice Address - Phone:831-854-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty