Healthcare Provider Details

I. General information

NPI: 1396283420
Provider Name (Legal Business Name): TABITHA L KIDD AS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

IV. Provider business mailing address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax:
Mailing address:
  • Phone: 740-534-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: