Provider Demographics
NPI:1376141564
Name:KIDNOCKER, PETER SHANE (CDCA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:SHANE
Last Name:KIDNOCKER
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3933
Mailing Address - Country:US
Mailing Address - Phone:740-876-4370
Mailing Address - Fax:740-529-1313
Practice Address - Street 1:519 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3933
Practice Address - Country:US
Practice Address - Phone:740-876-4370
Practice Address - Fax:740-529-1313
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)