Provider Demographics
NPI:1023859238
Name:TIDWELL, KATIE (PTA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28563 COLLINS FARM RD
Mailing Address - Street 2:
Mailing Address - City:MILLSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19966-1534
Mailing Address - Country:US
Mailing Address - Phone:302-236-6913
Mailing Address - Fax:
Practice Address - Street 1:110 W NORTH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2144
Practice Address - Country:US
Practice Address - Phone:302-856-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant