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General NPI Number Information
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NPI Number | 1326804352
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Entity Type | Individual
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Provider Name | ZYNYA RICHELL TIDWELL DP-CPRM
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Gender | Female
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Dates
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Enumeration Date | 02/27/2024
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Last Update Date | 02/27/2024
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Provider Practice Location Address
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Address Line | 4875 COPLIN ST
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City | DETROIT
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State | MI
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Zip | 48215-2192
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Country | US
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Telephone | 313-822-1135
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Fax | 313-822-1157
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Provider Business Mailing Address
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Address Line | 26450 CROCKER BLVD APT 1104
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City | HARRISON TOWNSHIP
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State | MI
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Zip | 48045-2497
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Country | US
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Telephone | 313-753-4470
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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