Provider Demographics
NPI:1518111913
Name:WIDEMAN, BARRY MICHAEL (LISW)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:MICHAEL
Last Name:WIDEMAN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428-9000
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:937-267-3924
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:937-267-3924
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH954293101YA0400X
OHI08000831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)