Provider Demographics
NPI:1659838522
Name:WIDENER, AMANDA MAE
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MAE
Last Name:WIDENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-4305
Mailing Address - Country:US
Mailing Address - Phone:405-489-2179
Mailing Address - Fax:
Practice Address - Street 1:1816 8TH AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4305
Practice Address - Country:US
Practice Address - Phone:405-489-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 101YP2500X, 146N00000X, 171M00000X, 172A00000X, 390200000X, 172V00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA116993628OtherDUNS
CA1659838522Medicaid