Provider Demographics
NPI:1326465881
Name:FIDA, KRISTIN (MED)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:FIDA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6826
Mailing Address - Country:US
Mailing Address - Phone:866-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:14711 EAGLEMONT DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-2733
Practice Address - Country:US
Practice Address - Phone:325-227-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-23
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-13966103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst