Basic Information
| Provider Information | |||||||||
| NPI: | 1164665063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIDWELL | ||||||||
| FirstName: | RODNEY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | REGISTERED STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11169 PIT RIVER CT | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956702919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162831514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4441 AUBURN BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958414139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164735764 | ||||||||
| FaxNumber: | 9164735766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.