Basic Information
| Provider Information | |||||||||
| NPI: | 1720233166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDWELL | ||||||||
| FirstName: | LYNETTE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 3RD ST N | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337036123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772684329 | ||||||||
| FaxNumber: | 7278961017 | ||||||||
| Practice Location | |||||||||
| Address1: | 3305 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328066125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078523300 | ||||||||
| FaxNumber: | 4078523334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2008 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ4684 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000-570-800 | 05 | FL | MEDICAID |