Provider Demographics
NPI:1265807069
Name:WIDNER, GRESSA
Entity type:Individual
Prefix:
First Name:GRESSA
Middle Name:
Last Name:WIDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRESSA
Other - Middle Name:
Other - Last Name:JOHANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3729 KLINDT DR
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3566
Mailing Address - Country:US
Mailing Address - Phone:541-298-2101
Mailing Address - Fax:541-298-7796
Practice Address - Street 1:3729 KLINDT DR
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3566
Practice Address - Country:US
Practice Address - Phone:541-298-2101
Practice Address - Fax:541-298-7796
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106S00000X
ORABA-B-10250168103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician