Provider Demographics
NPI:1043334980
Name:KIDWELL, CHARLES WILLIAM (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14950 S PONDEROSA WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-7627
Mailing Address - Country:US
Mailing Address - Phone:530-272-1114
Mailing Address - Fax:
Practice Address - Street 1:2008 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2135
Practice Address - Country:US
Practice Address - Phone:916-973-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical