Provider Demographics
NPI:1568851392
Name:WIDMAN, FREDRICK CARL (CAC II, CADC II, CDP)
Entity Type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:CARL
Last Name:WIDMAN
Suffix:
Gender:M
Credentials:CAC II, CADC II, CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11160 HURON ST STE 32
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80234-3335
Mailing Address - Country:US
Mailing Address - Phone:720-510-9115
Mailing Address - Fax:720-510-9103
Practice Address - Street 1:11160 HURON ST STE 32
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-3335
Practice Address - Country:US
Practice Address - Phone:720-510-9115
Practice Address - Fax:720-510-9103
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60144815101YA0400X
OR13-R-26101YA0400X
COACB.0008070101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)