Healthcare Provider Details

I. General information

NPI: 1013373596
Provider Name (Legal Business Name): ABIGAIL TIDBALL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 SHANAHAN RD STE 100
LEWIS CENTER OH
43035-9192
US

IV. Provider business mailing address

1776 FORD RD
DELAWARE OH
43015-7828
US

V. Phone/Fax

Practice location:
  • Phone: 937-206-2090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11357
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: