Provider Demographics
NPI:1619431301
Name:WIDENER, LORI LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:LEE
Last Name:WIDENER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 LYCEUM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4815
Mailing Address - Country:US
Mailing Address - Phone:503-944-9353
Mailing Address - Fax:
Practice Address - Street 1:329 LYCEUM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-4815
Practice Address - Country:US
Practice Address - Phone:503-944-9353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0192991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty