Provider Demographics
NPI:1417418591
Name:WIDHALM, STEPHANIE (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WIDHALM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2053
Mailing Address - Country:US
Mailing Address - Phone:509-473-4810
Mailing Address - Fax:509-473-4840
Practice Address - Street 1:1321 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2053
Practice Address - Country:US
Practice Address - Phone:509-473-4810
Practice Address - Fax:509-473-4840
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60331678104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker