Individual
MALIA TIDWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
112 W CITRUS ST, ALTAMONTE SPRINGS, FL 32714-2502
(407) 865-5642
Mailing address
305 E PINEWOOD CT, LAKE MARY, FL 32746-5900
(407) 923-4090
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA209020
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PTA209020
FL LICENSE NUMBER
FL
Enumeration date
01/15/2019
Last updated
01/15/2019
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