Healthcare Provider Details

I. General information

NPI: 1992147185
Provider Name (Legal Business Name): TALIAH S TIDWELL OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7705 RUGBY ST
PHILADELPHIA PA
19150-2507
US

IV. Provider business mailing address

508 E BRINTON ST
PHILADELPHIA PA
19144-1063
US

V. Phone/Fax

Practice location:
  • Phone: 215-868-4171
  • Fax:
Mailing address:
  • Phone: 215-520-6325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC012919
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: