Provider Demographics
NPI:1982371597
Name:KIDA, SHUNJIRO CLIFFORD
Entity Type:Individual
Prefix:
First Name:SHUNJIRO
Middle Name:CLIFFORD
Last Name:KIDA
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 1:1853 MANN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3433
Mailing Address - Country:US
Mailing Address - Phone:802-338-0822
Mailing Address - Fax:
Practice Address - Street 1:901 AVENIDA DE LAS CAMPANAS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-5369
Practice Address - Country:US
Practice Address - Phone:505-467-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCF7440235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist