Provider Demographics
NPI:1770354359
Name:KIDWELL, KATELYN M (MA, RDT ,LCAT)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:M
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:MA, RDT ,LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BLOOMFIELD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4352
Mailing Address - Country:US
Mailing Address - Phone:862-283-0386
Mailing Address - Fax:
Practice Address - Street 1:680 BLOOMFIELD AVE APT 2
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4352
Practice Address - Country:US
Practice Address - Phone:862-283-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002670-01101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist