Provider Demographics
NPI:1740424506
Name:WIDEMAN, SHANNA (MA, AADC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:
Last Name:WIDEMAN
Suffix:
Gender:F
Credentials:MA, AADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 MID ATLANTIC PKWY STE 3
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-7468
Mailing Address - Country:US
Mailing Address - Phone:304-260-6360
Mailing Address - Fax:
Practice Address - Street 1:397 MID ATLANTIC PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-7468
Practice Address - Country:US
Practice Address - Phone:304-260-6360
Practice Address - Fax:304-260-6459
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation