Provider Demographics
NPI:1821353616
Name:WIDNER, JAMES HERMAN JR (LADAC, CADAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HERMAN
Last Name:WIDNER
Suffix:JR
Gender:M
Credentials:LADAC, CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2355
Mailing Address - Country:US
Mailing Address - Phone:505-224-9777
Mailing Address - Fax:505-224-9779
Practice Address - Street 1:912 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2355
Practice Address - Country:US
Practice Address - Phone:505-224-9777
Practice Address - Fax:505-224-9779
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0133671101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)