Provider Demographics
NPI:1124101159
Name:KIDD, LAURIE (PSYD)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 AIRPORT RD STE E
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4025
Mailing Address - Country:US
Mailing Address - Phone:850-832-1075
Mailing Address - Fax:850-769-2366
Practice Address - Street 1:508 AIRPORT RD STE E
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4025
Practice Address - Country:US
Practice Address - Phone:850-832-1075
Practice Address - Fax:850-769-2366
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ035ROtherBCBS OF FL
FLK6265Medicare ID - Type UnspecifiedGROUP NUMBER