Provider Demographics
NPI:1053610667
Name:KIDD, DORA (LBSW)
Entity type:Individual
Prefix:MISS
First Name:DORA
Middle Name:
Last Name:KIDD
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17546 GATEWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4716
Mailing Address - Country:US
Mailing Address - Phone:248-552-1552
Mailing Address - Fax:
Practice Address - Street 1:12800 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2061
Practice Address - Country:US
Practice Address - Phone:313-824-8000
Practice Address - Fax:313-824-5589
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802071799104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker