MEDICARE: EMILY KIDWELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	65789	TX

General Provider Information

NPI Number	:	1831940311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY KIDWELL LCSW

Provider Business Mailing Address
First Line	:	1136 WOODVALE DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-2328
Country	:	US
Telephone Number	:	817-721-1187
Fax Number	:

Provider Business Practice Location Address
First Line	:	1136 WOODVALE DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76021-2328
Country	:	US
Telephone Number	:	817-721-1187
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/01/2024

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