MEDICARE: AMANDA KIDD LSW

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	149030218	IL

General Provider Information

NPI Number	:	1831837848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA KIDD LSW

Provider Business Mailing Address
First Line	:	3155 OLSEN DR STE 375
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95117-1688
Country	:	US
Telephone Number	:	219-677-6581
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 43RD ST
Second Line	:
City	:	HIGHLAND
State	:	IN
Zip	:	46322-3133
Country	:	US
Telephone Number	:	219-677-6581
Fax Number	:

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

Provider Enumeration Date	:	05/20/2022
Last Update Date	:	06/01/2026

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