Provider Demographics
NPI:1740080308
Name:TIDWELL, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 E 96TH DR
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2400
Mailing Address - Country:US
Mailing Address - Phone:720-936-0771
Mailing Address - Fax:
Practice Address - Street 1:1851 E 96TH DR
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2400
Practice Address - Country:US
Practice Address - Phone:888-329-4535
Practice Address - Fax:844-965-4535
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician