Provider Demographics
NPI:1043496680
Name:KIDWELL, MARVIN CARL
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:CARL
Last Name:KIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3501
Mailing Address - Country:US
Mailing Address - Phone:859-457-1679
Mailing Address - Fax:859-278-3451
Practice Address - Street 1:274 SOUTHLAND DR
Practice Address - Street 2:SUITE # 204
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1946
Practice Address - Country:US
Practice Address - Phone:859-457-1679
Practice Address - Fax:859-278-3451
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1058101YP2500X
FLMH8993101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical