Healthcare Provider Details

I. General information

NPI: 1700967577
Provider Name (Legal Business Name): JAMES WILLLIAM KIDWELL MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VA CENTER 122B VA HOSPITAL
AUGUSTA ME
04330
US

IV. Provider business mailing address

34 GREENLIEF ST
AUGUSTA ME
04330-5325
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax: 207-623-5719
Mailing address:
  • Phone: 207-622-4895
  • Fax: 207-622-4895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5916
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: