Provider Demographics
NPI:1205293503
Name:KIDD, BROOKE RENEE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:RENEE
Last Name:KIDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WORMAN DR
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3239
Mailing Address - Country:US
Mailing Address - Phone:419-296-3944
Mailing Address - Fax:
Practice Address - Street 1:105 WORMAN DR
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:OH
Practice Address - Zip Code:45322-3239
Practice Address - Country:US
Practice Address - Phone:419-296-3944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer