Provider Demographics
NPI:1053578179
Name:AMY L. WIDENBAUM, LMSW, PC
Entity type:Organization
Organization Name:AMY L. WIDENBAUM, LMSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIDENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-568-9680
Mailing Address - Street 1:18420 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3588
Mailing Address - Country:US
Mailing Address - Phone:248-568-9680
Mailing Address - Fax:
Practice Address - Street 1:18420 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3588
Practice Address - Country:US
Practice Address - Phone:248-568-9680
Practice Address - Fax:734-425-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010662371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION81310Medicare PIN