Provider Demographics
NPI:1639419187
Name:KIDD, GARRETT N
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:N
Last Name:KIDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1128
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-545-4100
Practice Address - Street 1:1302 CHINOOK LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1851
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:719-545-4100
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
TX2133756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No101Y00000XBehavioral Health & Social Service ProvidersCounselor