Provider Demographics
NPI:1255153094
Name:WIDEMAN, DENNIS DARNELL II
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:DARNELL
Last Name:WIDEMAN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2547 FLORIDIANE DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2816
Mailing Address - Country:US
Mailing Address - Phone:321-271-8115
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:772-463-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical