Provider Demographics
NPI:1851615785
Name:WIDGER, THOMAS JERNAGEN (MA, BCBA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JERNAGEN
Last Name:WIDGER
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 41ST ST
Mailing Address - Street 2:APT. A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-290-6732
Mailing Address - Fax:510-735-9725
Practice Address - Street 1:477 41ST ST
Practice Address - Street 2:APT. A
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-290-6732
Practice Address - Fax:510-735-9725
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1031464103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst