Provider Demographics
NPI:1578201513
Name:KIDWELL, LACEE NICOLE
Entity Type:Individual
Prefix:
First Name:LACEE
Middle Name:NICOLE
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 A SOUTH WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411
Mailing Address - Country:US
Mailing Address - Phone:304-582-1993
Mailing Address - Fax:
Practice Address - Street 1:703 A SOUTH WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411
Practice Address - Country:US
Practice Address - Phone:304-582-1993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health