Healthcare Provider Details

I. General information

NPI: 1194023606
Provider Name (Legal Business Name): BRANT TIDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 W 4100 S
WEST VALLEY CITY UT
84120-5543
US

IV. Provider business mailing address

3725 W 4100 S STE 201
WEST VALLEY CITY UT
84120-6490
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number380829-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: