Provider Demographics
NPI:1497518328
Name:WIDEMAN, DANA MOKRZYCKA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:MOKRZYCKA
Last Name:WIDEMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 S SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3751
Mailing Address - Country:US
Mailing Address - Phone:650-328-5645
Mailing Address - Fax:
Practice Address - Street 1:241 S SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-3751
Practice Address - Country:US
Practice Address - Phone:650-328-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11581103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical