Provider Demographics
NPI:1023561446
Name:KIDD, CALLIE C
Entity Type:Individual
Prefix:MRS
First Name:CALLIE
Middle Name:C
Last Name:KIDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 LANE 11
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-9212
Mailing Address - Country:US
Mailing Address - Phone:307-754-2606
Mailing Address - Fax:
Practice Address - Street 1:924 LANE 11
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-9212
Practice Address - Country:US
Practice Address - Phone:307-754-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services