Provider Demographics
NPI:1821512484
Name:WIDENER, MICHAEL J (RECOVERY ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WIDENER
Suffix:
Gender:M
Credentials:RECOVERY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 SHAKE RAG RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-6629
Mailing Address - Country:US
Mailing Address - Phone:501-303-3105
Mailing Address - Fax:
Practice Address - Street 1:242 SHAKE RAG RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6629
Practice Address - Country:US
Practice Address - Phone:501-303-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator