Provider Demographics
NPI:1568933547
Name:MCKIDDY, DANIELLE MARIE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:MCKIDDY
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 1:283 SE FOWLER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3309
Mailing Address - Country:US
Mailing Address - Phone:541-643-9366
Mailing Address - Fax:
Practice Address - Street 1:283 SE FOWLER ST STE 2
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3309
Practice Address - Country:US
Practice Address - Phone:541-643-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor