Provider Demographics
NPI:1457992539
Name:TIDWELL, TAYLOR SMITH (OTR)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:SMITH
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEIGH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 OWENS RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2885 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4808
Practice Address - Country:US
Practice Address - Phone:707-443-1627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4892225X00000X
KS17-03531225X00000X
CA20197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist