Healthcare Provider Details

I. General information

NPI: 1114551231
Provider Name (Legal Business Name): JANESSA LYNN TIDWELL CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13575 W MCDOWELL RD
GOODYEAR AZ
85395-2604
US

IV. Provider business mailing address

12376 W DEVONSHIRE AVE
AVONDALE AZ
85392-4258
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-9911
  • Fax:
Mailing address:
  • Phone: 417-650-1146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP12279
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: