Provider Demographics
NPI:1265867923
Name:KIDWELL PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:KIDWELL PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:763-566-0088
Mailing Address - Street 1:8441 WAYZATA BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1344
Mailing Address - Country:US
Mailing Address - Phone:651-482-9361
Mailing Address - Fax:
Practice Address - Street 1:8441 WAYZATA BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-1344
Practice Address - Country:US
Practice Address - Phone:651-482-9361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5403103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty