Provider Demographics
NPI:1770501843
Name:WIDICK, CAROLE ANNE (LP)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:ANNE
Last Name:WIDICK
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 2ND ST S STE 301
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1314
Mailing Address - Country:US
Mailing Address - Phone:320-252-2976
Mailing Address - Fax:320-656-1570
Practice Address - Street 1:110 2ND ST S STE 301
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1314
Practice Address - Country:US
Practice Address - Phone:320-252-2976
Practice Address - Fax:320-656-1570
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1899103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN491351500Medicaid
MN491351500Medicaid