Provider Demographics
NPI:1518691104
Name:KIDD, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KIDD
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 1:1100 E 80TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1426
Mailing Address - Country:US
Mailing Address - Phone:952-956-3144
Mailing Address - Fax:612-869-3225
Practice Address - Street 1:1100 E 80TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1426
Practice Address - Country:US
Practice Address - Phone:952-956-3144
Practice Address - Fax:612-869-3225
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health