Provider Demographics
NPI:1932305091
Name:TIDWELL, LACINDA SUE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:LACINDA
Middle Name:SUE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 DANESMOOR CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9510
Mailing Address - Country:US
Mailing Address - Phone:419-865-2607
Mailing Address - Fax:
Practice Address - Street 1:2920 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-1716
Practice Address - Country:US
Practice Address - Phone:419-242-7458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001895225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant