Basic Information
| Provider Information | |||||||||
| NPI: | 1144537408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | MA ED., LPCC/LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 933132 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307245471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3445 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COVENTRY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306444095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2010 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 944030 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | E.0002371-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0164022 | 05 | OH | MEDICAID |