Provider Demographics
NPI:1821875600
Name:FREDRICK C. WIDMAN
Entity Type:Organization
Organization Name:FREDRICK C. WIDMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-345-4568
Mailing Address - Street 1:2930 MADISON LN
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4522
Mailing Address - Country:US
Mailing Address - Phone:303-345-4568
Mailing Address - Fax:
Practice Address - Street 1:11160 HURON ST STE 32
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-3335
Practice Address - Country:US
Practice Address - Phone:720-510-9115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty