Provider Demographics
NPI:1336455872
Name:KIDDER, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:KIDDER
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 1:3552 BIRCHWOOD LN SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-1647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:343 WOODLAKE DR SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6242
Practice Address - Country:US
Practice Address - Phone:507-535-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN170351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical