Healthcare Provider Details

I. General information

NPI: 1407180862
Provider Name (Legal Business Name): DEBORAH BRADER KIDWELL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SAINT CLAIRE PL STE 202
STEVENSVILLE MD
21666-2193
US

IV. Provider business mailing address

2141 LOVE POINT RD
STEVENSVILLE MD
21666-2051
US

V. Phone/Fax

Practice location:
  • Phone: 410-703-2816
  • Fax:
Mailing address:
  • Phone: 410-703-2816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4030
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: