Provider Demographics
NPI:1215537477
Name:KIDDER, HANNAH MAE (LADC)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:MAE
Last Name:KIDDER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:MAE
Other - Last Name:FORNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:1370 MENDOTA HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1281
Mailing Address - Country:US
Mailing Address - Phone:651-313-8080
Mailing Address - Fax:
Practice Address - Street 1:6040 EARLE BROWN DR STE 100
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2561
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4470101YM0800X
MN303758101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty