Provider Demographics
NPI:1639323413
Name:KIDDER, STACEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3662 WESTVALE DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-9110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 SYKES ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-1231
Practice Address - Country:US
Practice Address - Phone:607-543-0162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008449-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist