Provider Demographics
NPI:1689740755
Name:KIDDER, ROBERT L (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:KIDDER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9861 LEGOLAS LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7020
Mailing Address - Country:US
Mailing Address - Phone:704-766-2947
Mailing Address - Fax:
Practice Address - Street 1:110 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:MCMURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-2685
Practice Address - Country:US
Practice Address - Phone:724-941-4070
Practice Address - Fax:724-941-5083
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0147041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013931270001Medicaid
PA034496H5BMedicare ID - Type Unspecified
NC1689740755Medicare PIN