Provider Demographics
NPI:1023506615
Name:KIDDERS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KIDDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KIDDERS-MONTOYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:435 VILLAGE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-4810
Mailing Address - Country:US
Mailing Address - Phone:708-217-0330
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PL
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6603
Practice Address - Country:US
Practice Address - Phone:847-695-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-29
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA758101200000X
MA12591-MH-CC101YM0800X
IL180.017281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist