Provider Demographics
NPI:1679806533
Name:WIDOWS, MICHELLE RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENEE
Last Name:WIDOWS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:RENEE WIDOWS
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:515 CITY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-8016
Mailing Address - Country:US
Mailing Address - Phone:912-249-4400
Mailing Address - Fax:912-279-4448
Practice Address - Street 1:515 CITY BLVD STE B
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8016
Practice Address - Country:US
Practice Address - Phone:912-249-4400
Practice Address - Fax:912-279-4448
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3155103T00000X, 103TC0700X, 103TH0004X
FLPY6699103T00000X, 103TC0700X
FLPY669103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth