Healthcare Provider Details

I. General information

NPI: 1336493477
Provider Name (Legal Business Name): KELLY KAE BIDWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2012
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18201 CONNEAUT LAKE RD
MEADVILLE PA
16335-3757
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 814-333-5060
  • Fax: 814-333-5067
Mailing address:
  • Phone: 814-373-2923
  • Fax: 814-333-5187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017481
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: