Healthcare Provider Details

I. General information

NPI: 1538088331
Provider Name (Legal Business Name): KENNETH DALE WIDICK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E 37TH ST
GARDEN CITY ID
83714-6419
US

IV. Provider business mailing address

PO BOX 8803
BOISE ID
83707-2803
US

V. Phone/Fax

Practice location:
  • Phone: 208-331-0900
  • Fax: 208-331-0904
Mailing address:
  • Phone: 208-412-8338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-31550
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: