Individual
MR. MARK DUSTIN TIDWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1218 GRIEGOS RD NW, ALBUQUERQUE, NM 87107
(505) 345-8471
Mailing address
1218 GRIEGOS ROAD NORTH WEST, HOGARES, ALBUQUERQUE, NM 87107
(505) 345-8471
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
504368441
NM
Other
Enumeration date
07/01/2011
Last updated
07/01/2011
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