Provider Demographics
NPI:1528933694
Name:TIDWELL, OLIVIA NEVAEH
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NEVAEH
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 1:20933 SIOUX RD APT 4
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-4231
Mailing Address - Country:US
Mailing Address - Phone:909-343-7325
Mailing Address - Fax:
Practice Address - Street 1:3333 CONCOURS STE 4102
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-6564
Practice Address - Country:US
Practice Address - Phone:909-240-1764
Practice Address - Fax:909-259-2369
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician