Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XH1200X | Occupational Therapist - Hand | 8534 | NC |
NPI | 1063901668 |
---|---|
Provider Name | Angela Mary Tidwell |
First Address | Mooresville, NC 28117-7042 |
Second Address | Mooresville, NC 28117-6959 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2018 |
Last Update Date | 09/05/2018 |