Healthcare Provider Details

I. General information

NPI: 1720863640
Provider Name (Legal Business Name): KATE KIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 S MICHIGAN AVE STE 900
CHICAGO IL
60604-4393
US

IV. Provider business mailing address

62 ALDER WAY
ROUND LAKE IL
60073-1630
US

V. Phone/Fax

Practice location:
  • Phone: 813-395-1073
  • Fax:
Mailing address:
  • Phone: 773-288-9634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-284383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: