Provider Demographics
NPI:1720233166
Name:KIDWELL, LYNETTE MICHELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:MICHELLE
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 3RD ST N
Mailing Address - Street 2:SUITE D
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-6123
Mailing Address - Country:US
Mailing Address - Phone:877-268-4329
Mailing Address - Fax:727-896-1017
Practice Address - Street 1:3305 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6125
Practice Address - Country:US
Practice Address - Phone:407-852-3300
Practice Address - Fax:407-852-3334
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000-570-800Medicaid