Provider Demographics
NPI:1730515339
Name:BIDINGER, KEVIN RICHARD (SAC-IT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RICHARD
Last Name:BIDINGER
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W OLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-2142
Mailing Address - Country:US
Mailing Address - Phone:608-255-5922
Mailing Address - Fax:608-255-0340
Practice Address - Street 1:810 W OLIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-2142
Practice Address - Country:US
Practice Address - Phone:608-255-5922
Practice Address - Fax:608-255-0340
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16954-130101YA0400X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417112780Medicaid