Provider Demographics
NPI:1194182071
Name:KIDWELL, JOHN (PSYD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 E ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6520
Mailing Address - Country:US
Mailing Address - Phone:610-865-1699
Mailing Address - Fax:610-419-3446
Practice Address - Street 1:19 E ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-6520
Practice Address - Country:US
Practice Address - Phone:610-865-1699
Practice Address - Fax:610-419-3446
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA542083365Medicaid