Provider Demographics
NPI:1306015185
Name:KIDDER, MARCIA W (PT)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:W
Last Name:KIDDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 SOUTHCREST CIR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6730
Mailing Address - Country:US
Mailing Address - Phone:662-536-0900
Mailing Address - Fax:662-536-0914
Practice Address - Street 1:391 SOUTHCREST CIR
Practice Address - Street 2:SUITE 205
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6730
Practice Address - Country:US
Practice Address - Phone:662-536-0900
Practice Address - Fax:662-536-0914
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0274225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist