Provider Demographics
NPI:1477106961
Name:LIDESTRI, KATHERINE MICHELLE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELLE
Last Name:LIDESTRI
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 1:15 INDIAN HEAD TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2032
Mailing Address - Country:US
Mailing Address - Phone:401-580-9046
Mailing Address - Fax:
Practice Address - Street 1:43 BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-1977
Practice Address - Country:US
Practice Address - Phone:401-596-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor