Provider Demographics
NPI:1023889110
Name:IDLEWINE, EMILY NICOLE (LPCA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:IDLEWINE
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:419-695-1010
Mailing Address - Fax:606-695-8010
Practice Address - Street 1:3540 S HIGHWAY 27 STE 4
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3124
Practice Address - Country:US
Practice Address - Phone:606-679-1815
Practice Address - Fax:606-451-1631
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY127180101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY127180OtherLPCA