Provider Demographics
NPI:1558098004
Name:WIDENER, ALEXANDRIA (LCMHCA)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRIA
Middle Name:
Last Name:WIDENER
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1246
Mailing Address - Country:US
Mailing Address - Phone:276-206-4132
Mailing Address - Fax:704-531-9266
Practice Address - Street 1:769 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1118
Practice Address - Country:US
Practice Address - Phone:704-376-7180
Practice Address - Fax:704-531-9266
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17915101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health