Provider Demographics
NPI:1164665063
Name:KIDWELL, RODNEY ALLEN (REGISTERED STUDENT)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:ALLEN
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:REGISTERED STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11169 PIT RIVER CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-2919
Mailing Address - Country:US
Mailing Address - Phone:916-283-1514
Mailing Address - Fax:
Practice Address - Street 1:4441 AUBURN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4139
Practice Address - Country:US
Practice Address - Phone:916-473-5764
Practice Address - Fax:916-473-5766
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)