Provider Demographics
NPI:1467580670
Name:KIDWELL, COURTNEY SMITH (PT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:SMITH
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 COUNTY ROAD 2720
Mailing Address - Street 2:
Mailing Address - City:MICO
Mailing Address - State:TX
Mailing Address - Zip Code:78056-5400
Mailing Address - Country:US
Mailing Address - Phone:903-372-4626
Mailing Address - Fax:
Practice Address - Street 1:1901 BABCOCK RD STE 204
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4546
Practice Address - Country:US
Practice Address - Phone:210-342-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1169663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist