Healthcare Provider Details

I. General information

NPI: 1023889110
Provider Name (Legal Business Name): EMILY NICOLE IDLEWINE LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 S HIGHWAY 27 STE 4
SOMERSET KY
42501-3124
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9058
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-1815
  • Fax: 606-451-1631
Mailing address:
  • Phone: 419-695-1010
  • Fax: 606-695-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number127180
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: