Provider Demographics
NPI:1710007109
Name:KIDD, SCOTT T (PSYD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:KIDD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2378 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2009
Mailing Address - Country:US
Mailing Address - Phone:937-879-7996
Mailing Address - Fax:
Practice Address - Street 1:2378 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-2009
Practice Address - Country:US
Practice Address - Phone:937-879-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5975103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic