Provider Demographics
NPI:1649726233
Name:KIDDER, STACI (LMSW)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 FRANKFORT HWY
Mailing Address - Street 2:STE. 200
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-9558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY
Practice Address - Street 2:STE. 200
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9558
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010728061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical