Provider Demographics
NPI:1689753089
Name:BIDWELL, ALICE SUSAN (CNS)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:SUSAN
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BIDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNS
Mailing Address - Street 1:11250 ROGER BACON DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5219
Mailing Address - Country:US
Mailing Address - Phone:703-424-0461
Mailing Address - Fax:
Practice Address - Street 1:11250 ROGER BACON DR
Practice Address - Street 2:SUITE 12
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5219
Practice Address - Country:US
Practice Address - Phone:703-424-0461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000280364SP0808X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Not Answered364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5510241Medicaid
VA239232OtherANTHEM BLUE CROSS