Basic Information
| Provider Information | |||||||||
| NPI: | 1639419187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | GARRETT | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1026 W ABRIENDO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810041128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195452746 | ||||||||
| FaxNumber: | 7195454100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 CHINOOK LN | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810011851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195452746 | ||||||||
| FaxNumber: | 7195454100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2013 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 225200000X | 2133756 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.