Healthcare Provider Details

I. General information

NPI: 1871103051
Provider Name (Legal Business Name): CARIL ELIZABETH TIDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6715 LITTLE RIVER TPKE STE 200
ANNANDALE VA
22003-3546
US

IV. Provider business mailing address

79 POTOMAC AVE SE APT 618
WASHINGTON DC
20003-3691
US

V. Phone/Fax

Practice location:
  • Phone: 703-879-2479
  • Fax: 703-879-2803
Mailing address:
  • Phone: 704-779-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204000546
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202009991
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: