Healthcare Provider Details

I. General information

NPI: 1275211708
Provider Name (Legal Business Name): ELIZABETH E TIDEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5163 ROSWELL RD
ATLANTA GA
30342-2206
US

IV. Provider business mailing address

69 ROSWELL CT NE
ATLANTA GA
30305-1411
US

V. Phone/Fax

Practice location:
  • Phone: 877-288-4760
  • Fax:
Mailing address:
  • Phone: 863-279-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: