Provider Demographics
NPI:1740069749
Name:KIDD, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
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 1:3473 RIDER TRL S
Mailing Address - Street 2:
Mailing Address - City:EARTH CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63045-1110
Mailing Address - Country:US
Mailing Address - Phone:314-328-0088
Mailing Address - Fax:
Practice Address - Street 1:160 CEDAR TREE SQ
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2132
Practice Address - Country:US
Practice Address - Phone:816-281-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1764237700000X
MO2021012819237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist