Provider Demographics
NPI:1609647627
Name:TIDWELL, KRISTINA JOAN (APCC)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:JOAN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 CENTRAL AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1701
Mailing Address - Country:US
Mailing Address - Phone:909-708-5106
Mailing Address - Fax:
Practice Address - Street 1:200 IKE DR
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9718
Practice Address - Country:US
Practice Address - Phone:808-316-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14095101YM0800X
HI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health