Basic Information
| Provider Information | |||||||||
| NPI: | 1609108703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIDWELL | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 111 DEAN ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153445061 | ||||||||
| FaxNumber: | 8153445072 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 DEAN ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153445061 | ||||||||
| FaxNumber: | 8153445072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2010 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071.007831 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP0016X | 074.000011 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No ID Information.