Provider Demographics
NPI:1043768500
Name:STIDD, KATHLEEN (MA CMFC, MAT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:STIDD
Suffix:
Gender:F
Credentials:MA CMFC, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11845 SW GREENBURG RD STE 210
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6464
Mailing Address - Country:US
Mailing Address - Phone:503-719-3878
Mailing Address - Fax:
Practice Address - Street 1:11845 SW GREENBURG RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6464
Practice Address - Country:US
Practice Address - Phone:503-719-3878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6419101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor