Provider Demographics
NPI:1669934378
Name:TIDWELL, HEIDI OLSEN (PT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:OLSEN
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR STE 420
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7677
Mailing Address - Country:US
Mailing Address - Phone:801-295-8999
Mailing Address - Fax:
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR STE 420
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7677
Practice Address - Country:US
Practice Address - Phone:801-295-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT269056-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic