Provider Demographics
NPI:1457321457
Name:KIDDER, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:KIDDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:KIDDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1421 LEE ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-7132
Mailing Address - Country:US
Mailing Address - Phone:912-270-8025
Mailing Address - Fax:
Practice Address - Street 1:1421 LEE ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7132
Practice Address - Country:US
Practice Address - Phone:912-270-8025
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional