Provider Demographics
NPI:1942677471
Name:MACLEAN-WIDEMAN, MOIRA
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:MACLEAN-WIDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SHATTUCK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-2492
Mailing Address - Country:US
Mailing Address - Phone:978-222-3121
Mailing Address - Fax:
Practice Address - Street 1:40 SHATTUCK RD STE 250
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-2492
Practice Address - Country:US
Practice Address - Phone:978-222-3121
Practice Address - Fax:617-376-8910
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
MALMHC10002094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)