Provider Demographics
NPI:1801976634
Name:KIDD, STEPHANIE L (MA, MED, LPCC/PCC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:KIDD
Suffix:
Gender:F
Credentials:MA, MED, LPCC/PCC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:BIRNBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, MED, LPCC/PCC
Mailing Address - Street 1:6929 W 130TH ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7895
Mailing Address - Country:US
Mailing Address - Phone:440-481-3055
Mailing Address - Fax:440-481-3222
Practice Address - Street 1:6929 W 130TH ST
Practice Address - Street 2:SUITE 503
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-7895
Practice Address - Country:US
Practice Address - Phone:440-481-3055
Practice Address - Fax:440-481-3222
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0007819101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH587502OtherPROVIDER VO ID#
OH393335OtherPROVIDER MHN (HEALTHNET) ID#
OH2908413OtherUHC/UBH PROVIDER ID
OH2967384Medicaid