Provider Demographics
NPI:1114044575
Name:WIDNEY, DWIGHT EDWARD
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:EDWARD
Last Name:WIDNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STROHM RD
Mailing Address - Street 2:
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-9653
Mailing Address - Country:US
Mailing Address - Phone:717-532-3655
Mailing Address - Fax:
Practice Address - Street 1:210 BIG SPRING RD
Practice Address - Street 2:
Practice Address - City:NEWVILLE
Practice Address - State:PA
Practice Address - Zip Code:17241-9497
Practice Address - Country:US
Practice Address - Phone:717-776-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00446224Z00000X
PAOP006377224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant