Provider Demographics
NPI:1114659927
Name:WIDAS, ALEXANDER (BS, LMT, CHT, REV)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:WIDAS
Suffix:
Gender:M
Credentials:BS, LMT, CHT, REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 REDSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-8926
Mailing Address - Country:US
Mailing Address - Phone:609-351-1988
Mailing Address - Fax:
Practice Address - Street 1:323 WILSON WAY
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1938
Practice Address - Country:US
Practice Address - Phone:609-351-1988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
COMT.0024401225700000X
VT164.0000760225700000X
VT097.0135085101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist