Individual
KEITH TISDELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
189 DECKER, KYLE, TX 78640-5791
(954) 328-5436
Mailing address
189 DECKER, KYLE, TX 78640-5791
(954) 328-5436
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
10016
FL
225X00000X
Occupational Therapist
Primary
113654
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
887054300
—
FL
Enumeration date
07/03/2005
Last updated
01/11/2012
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