Provider Demographics
NPI:1265285407
Name:KIDD, TYRONE SABASTON
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:SABASTON
Last Name:KIDD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 CHATEAU DR APT H
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2734
Mailing Address - Country:US
Mailing Address - Phone:804-714-4563
Mailing Address - Fax:
Practice Address - Street 1:2211 CHATEAU DR APT H
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-2734
Practice Address - Country:US
Practice Address - Phone:804-714-4563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10760-07-006251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health