Provider Demographics
NPI:1780045674
Name:WIDDIS, KATHLEEN JOY (CDP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOY
Last Name:WIDDIS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3416
Mailing Address - Country:US
Mailing Address - Phone:425-259-5842
Mailing Address - Fax:425-259-0248
Practice Address - Street 1:2732 GRAND AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3416
Practice Address - Country:US
Practice Address - Phone:425-259-5842
Practice Address - Fax:425-259-0248
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60450937101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)