Provider Demographics
NPI:1558428276
Name:WIDENBAUM, AMY LYNN (MSW,LMSW,CSW,ACSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:WIDENBAUM
Suffix:
Gender:F
Credentials:MSW,LMSW,CSW,ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15645 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-2851
Mailing Address - Country:US
Mailing Address - Phone:248-568-9680
Mailing Address - Fax:734-425-6212
Practice Address - Street 1:15645 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-2851
Practice Address - Country:US
Practice Address - Phone:248-568-9680
Practice Address - Fax:734-425-6212
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010662371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI476528OtherVALUE OPTIONS
MI80-0-89-6782-0OtherBCBS
MI537109-000OtherMAGELLAN
MI80-0-89-6782-0OtherBCBS