Healthcare Provider Details

I. General information

NPI: 1730631359
Provider Name (Legal Business Name): COURTNEY TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 IROQUOIS AVE SUITE 402
NAPERVILLE IL
60563-8551
US

IV. Provider business mailing address

19631 CLIFTON WAY
MOKENA IL
60448-8158
US

V. Phone/Fax

Practice location:
  • Phone: 630-229-8843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: