Provider Demographics
NPI:1073000717
Name:WIDENHOFER, DEANNA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:WIDENHOFER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:MARIE
Other - Last Name:CHAMPAGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19219 COACHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7882
Mailing Address - Country:US
Mailing Address - Phone:734-363-3085
Mailing Address - Fax:
Practice Address - Street 1:10300 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2100
Practice Address - Country:US
Practice Address - Phone:248-691-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010932771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical