Provider Demographics
NPI:1164757399
Name:KIDD, TARAH JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:TARAH
Middle Name:JEAN
Last Name:KIDD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:DENISE
Other - Last Name:HARDWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 1721
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-1721
Mailing Address - Country:US
Mailing Address - Phone:859-755-6871
Mailing Address - Fax:
Practice Address - Street 1:65 N HIGHWAY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1540
Practice Address - Country:US
Practice Address - Phone:606-549-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008317101YA0400X
KY243668101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN40588671Medicaid
KY1164757399Medicaid