Provider Demographics
NPI:1578614285
Name:KIDD, JULIA (LICSW)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4673
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9597 STATE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02568
Practice Address - Country:US
Practice Address - Phone:508-696-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110579104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07757OtherBLUE CROSS
MAP22706Medicare ID - Type Unspecified