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General NPI Number Information
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NPI Number | 1477550630
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Entity Type | Individual
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Provider Name | KEITH TISDELL
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Gender | Male
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Dates
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Enumeration Date | 07/03/2005
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 189 DECKER
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City | KYLE
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State | TX
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Zip | 78640-5791
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Country | US
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Telephone | 954-328-5436
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Fax |
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Provider Business Mailing Address
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Address Line | 189 DECKER
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City | KYLE
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State | TX
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Zip | 78640-5791
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Country | US
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Telephone | 954-328-5436
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 10016
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 113654
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License Number State | FL
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