Provider Demographics
NPI:1699083808
Name:KIDWELL, LORI (PC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BETHEL RD FL 1
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2690
Mailing Address - Country:US
Mailing Address - Phone:614-538-0353
Mailing Address - Fax:
Practice Address - Street 1:1115 BETHEL RD FL 1
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2690
Practice Address - Country:US
Practice Address - Phone:614-538-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN360518101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor