Provider Demographics
NPI:1306273743
Name:LIDVALL, KRISTIN (OTD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:LIDVALL
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-1925
Mailing Address - Country:US
Mailing Address - Phone:865-850-5944
Mailing Address - Fax:
Practice Address - Street 1:1500 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3229
Practice Address - Country:US
Practice Address - Phone:360-423-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 60291976174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist