Provider Demographics
NPI:1366574204
Name:KIDDER, KIMBERLY G (SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:G
Last Name:KIDDER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BELLE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-993-3417
Mailing Address - Fax:
Practice Address - Street 1:1500 W WILLOW ST
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-5303
Practice Address - Country:US
Practice Address - Phone:337-521-7700
Practice Address - Fax:337-521-7701
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478202Medicaid