Healthcare Provider Details

I. General information

NPI: 1114517257
Provider Name (Legal Business Name): LAUREN D TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 K ST NW STE 300
WASHINGTON DC
20006-1012
US

IV. Provider business mailing address

2730 UNIVERSITY BLVD W STE 310
WHEATON MD
20902-1990
US

V. Phone/Fax

Practice location:
  • Phone: 301-942-7600
  • Fax: 202-419-0418
Mailing address:
  • Phone: 301-942-3126
  • Fax: 301-942-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: