Basic Information
| Provider Information | |||||||||
| NPI: | 1053610667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | DORA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17546 GATEWAY CIR | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480754716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485521552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12800 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138248000 | ||||||||
| FaxNumber: | 3138245589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2011 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802071799 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.