1801976634 NPI number — STEPHANIE L KIDD MA, MED, LPCC/PCC

Table of content: STEPHANIE L KIDD MA, MED, LPCC/PCC (NPI 1801976634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801976634 NPI number — STEPHANIE L KIDD MA, MED, LPCC/PCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDD
Provider First Name:
STEPHANIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, MED, LPCC/PCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIRNBAUM
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, MED, LPCC/PCC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801976634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6929 W 130TH ST
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44130-7895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-481-3055
Provider Business Mailing Address Fax Number:
440-481-3222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6929 W 130TH ST
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44130-7895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-481-3055
Provider Business Practice Location Address Fax Number:
440-481-3222
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  E0007819 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: E0007819 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 587502 . This is a "PROVIDER VO ID#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 393335 . This is a "PROVIDER MHN (HEALTHNET) ID#" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2908413 . This is a "UHC/UBH PROVIDER ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2967384 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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