Provider Demographics
NPI:1336172386
Name:WIDDER, RUSSELL P (LCSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:WIDDER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 EGRET LN
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:DE
Mailing Address - Zip Code:19934-4002
Mailing Address - Country:US
Mailing Address - Phone:302-736-1820
Mailing Address - Fax:302-736-5016
Practice Address - Street 1:148 S BRADFORD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-7318
Practice Address - Country:US
Practice Address - Phone:302-736-1820
Practice Address - Fax:302-736-5016
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00001801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000643973Medicaid
DES30242Medicare UPIN
DE0000643973Medicaid