Healthcare Provider Details

I. General information

NPI: 1376453423
Provider Name (Legal Business Name): ALISHA JADE KIDD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W WALNUT ST
SPRINGFIELD MO
65806-1640
US

IV. Provider business mailing address

2440 N EAST AVE
SPRINGFIELD MO
65803-3404
US

V. Phone/Fax

Practice location:
  • Phone: 417-818-5784
  • Fax:
Mailing address:
  • Phone: 417-818-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2840262
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: