Provider Demographics
NPI:1619955481
Name:WIDENER, ANN LOUISE (PHD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:LOUISE
Last Name:WIDENER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 RIBAUT RD
Mailing Address - Street 2:STE 2
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5486
Mailing Address - Country:US
Mailing Address - Phone:843-524-7920
Mailing Address - Fax:843-525-1230
Practice Address - Street 1:968 RIBAUT RD
Practice Address - Street 2:STE 2
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5486
Practice Address - Country:US
Practice Address - Phone:843-524-7920
Practice Address - Fax:843-525-1230
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC566231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0018Medicaid
SCGP1494Medicaid
Q27079Medicare UPIN