Provider Demographics
NPI:1508279928
Name:BIDWELL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DRONKERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, EDS
Mailing Address - Street 1:415 ROBERTS CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-7737
Mailing Address - Country:US
Mailing Address - Phone:850-273-8222
Mailing Address - Fax:
Practice Address - Street 1:415 ROBERTS CEMETERY RD
Practice Address - Street 2:
Practice Address - City:WEWAHITCHKA
Practice Address - State:FL
Practice Address - Zip Code:32465-7737
Practice Address - Country:US
Practice Address - Phone:850-273-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1264103TS0200X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health