Provider Demographics
NPI:1174035687
Name:KIDD, CAROL ANN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
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 1:1074 WASSERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:OH
Mailing Address - Zip Code:45103-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1074 WASSERMAN WAY
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1911
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC.121061-3101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLCDC.121061-3OtherLICENSURE