Healthcare Provider Details

I. General information

NPI: 1124101159
Provider Name (Legal Business Name): LAURIE KIDD PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 AIRPORT RD STE E
PANAMA CITY FL
32405-4025
US

IV. Provider business mailing address

508 AIRPORT RD STE E
PANAMA CITY FL
32405-4025
US

V. Phone/Fax

Practice location:
  • Phone: 850-832-1075
  • Fax: 850-769-2366
Mailing address:
  • Phone: 850-832-1075
  • Fax: 850-769-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: