Provider Demographics
NPI:1871016600
Name:BIRDWELL, KYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BIRDWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-3702
Mailing Address - Country:US
Mailing Address - Phone:601-319-2742
Mailing Address - Fax:
Practice Address - Street 1:110 PATTON AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6155
Practice Address - Country:US
Practice Address - Phone:601-582-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC82151041C0700X
MSM8215104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical