Provider Demographics
NPI:1427706282
Name:KIDDER, CAROLINE
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:KIDDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:
Other - Last Name:LANIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:103 MILL ST
Mailing Address - Street 2:
Mailing Address - City:COMO
Mailing Address - State:MS
Mailing Address - Zip Code:38619-9300
Mailing Address - Country:US
Mailing Address - Phone:662-560-7363
Mailing Address - Fax:
Practice Address - Street 1:5271 GETWELL RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9608
Practice Address - Country:US
Practice Address - Phone:662-772-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist