MEDICARE: ANGELA TIDWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1710286240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA TIDWELL

Provider Business Mailing Address
First Line	:	3601 NAUGATUCK CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6528
Country	:	US
Telephone Number	:	702-834-8515
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 NAUGATUCK CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6528
Country	:	US
Telephone Number	:	702-834-8515
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2011
Last Update Date	:	03/06/2012

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Directions to “ ANGELA TIDWELL ” Practice Location

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