MEDICARE: MARY KIDDER LCSW

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	34293	TX

General Provider Information

NPI Number	:	1134508468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KIDDER LCSW

Provider Business Mailing Address
First Line	:	750 N FIELDER RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76012-4635
Country	:	US
Telephone Number	:	214-232-3439
Fax Number	:	817-275-8601

Provider Business Practice Location Address
First Line	:	4223 LOMO ALTO CT
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1508
Country	:	US
Telephone Number	:	214-232-3439
Fax Number	:

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

Provider Enumeration Date	:	05/19/2015
Last Update Date	:	11/15/2021

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