Provider Demographics
NPI:1710742002
Name:KIDDER, DWIGHT (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:KIDDER
Suffix:
Gender:M
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 PHEASANT CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2866
Mailing Address - Country:US
Mailing Address - Phone:704-993-8067
Mailing Address - Fax:
Practice Address - Street 1:3208 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0800
Practice Address - Country:US
Practice Address - Phone:910-233-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0167031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical