Provider Demographics
NPI:1689935447
Name:BIDWELL, L. CINNAMON (PHD)
Entity Type:Individual
Prefix:
First Name:L.
Middle Name:CINNAMON
Last Name:BIDWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:POTTER 3
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-6573
Practice Address - Street 1:1 HOPPIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4141
Practice Address - Country:US
Practice Address - Phone:401-444-8945
Practice Address - Fax:401-444-8742
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01292103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPS01292OtherPROFESSIONAL LICENSE