Provider Demographics
NPI:1871103051
Name:TIDDY, CARIL ELIZABETH
Entity type:Individual
Prefix:
First Name:CARIL
Middle Name:ELIZABETH
Last Name:TIDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 POTOMAC AVE SE APT 618
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3691
Mailing Address - Country:US
Mailing Address - Phone:704-779-2619
Mailing Address - Fax:
Practice Address - Street 1:6715 LITTLE RIVER TPKE STE 200
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3546
Practice Address - Country:US
Practice Address - Phone:703-879-2479
Practice Address - Fax:703-879-2803
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000546235Z00000X
VA2202009991235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist