MEDICARE: TRACY JOAN RYAN KIDD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904001855	VA

General Provider Information

NPI Number	:	1720318231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY JOAN RYAN KIDD LCSW

Provider Business Mailing Address
First Line	:	410 MAPLE AVE W STE 7
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4224
Country	:	US
Telephone Number	:	703-281-9313
Fax Number	:	703-281-9769

Provider Business Practice Location Address
First Line	:	410 MAPLE AVE W STE 7
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4224
Country	:	US
Telephone Number	:	703-281-9313
Fax Number	:	703-281-9769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2010
Last Update Date	:	01/05/2010

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