Provider Demographics
NPI:1730283722
Name:KIDD, NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 LIVERNOIS
Mailing Address - Street 2:SUITE 700
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1639
Mailing Address - Country:US
Mailing Address - Phone:248-269-0230
Mailing Address - Fax:248-269-0231
Practice Address - Street 1:2265 LIVERNOIS
Practice Address - Street 2:SUITE 700
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1639
Practice Address - Country:US
Practice Address - Phone:248-269-0230
Practice Address - Fax:248-269-0231
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL929736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F396820OtherBLUE CROSS BLUE SHIELD
0P09750Medicare ID - Type Unspecified
MI650F396820OtherBLUE CROSS BLUE SHIELD