Healthcare Provider Details

I. General information

NPI: 1043526056
Provider Name (Legal Business Name): AMY VALENTINE TIDIK MA,CCC-SP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 GROVE ST
SAN LUIS OBISPO CA
93401-2914
US

IV. Provider business mailing address

5875 SALISBURY LN
SAN LUIS OBISPO CA
93401-8267
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-3945
  • Fax:
Mailing address:
  • Phone: 805-459-5775
  • Fax: 805-543-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number15475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: