Provider Demographics
NPI:1285905679
Name:KIDDER, JOANNA (LOT)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SGT PRENTISS DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4782
Mailing Address - Country:US
Mailing Address - Phone:601-446-8764
Mailing Address - Fax:601-446-8745
Practice Address - Street 1:55 SGT PRENTISS DR
Practice Address - Street 2:SUITE 8
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4782
Practice Address - Country:US
Practice Address - Phone:601-446-8764
Practice Address - Fax:601-446-8745
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1805225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation