Healthcare Provider Details

I. General information

NPI: 1760354039
Provider Name (Legal Business Name): ALYSON TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 NEW FORSYTH RD
MACON GA
31210-5770
US

IV. Provider business mailing address

1001 WALNUT ST UNIT A
MACON GA
31201-1904
US

V. Phone/Fax

Practice location:
  • Phone: 478-238-5757
  • Fax:
Mailing address:
  • Phone: 478-954-9631
  • 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: