Healthcare Provider Details

I. General information

NPI: 1023506615
Provider Name (Legal Business Name): KIMBERLY KIDDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY KIDDERS-MONTOYA

II. Dates (important events)

Enumeration Date: 04/29/2018
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 GRANDSTAND PL
ELGIN IL
60123-6603
US

IV. Provider business mailing address

435 VILLAGE CREEK DR
LAKE IN THE HILLS IL
60156-4810
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-0484
  • Fax:
Mailing address:
  • Phone: 708-217-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12591-MH-CC
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.017281
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number758
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: