Provider Demographics
NPI:1336854496
Name:WIDICK, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIDICK
Suffix:
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 1:11980 LAKE ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-2944
Mailing Address - Country:US
Mailing Address - Phone:561-306-3650
Mailing Address - Fax:
Practice Address - Street 1:11980 LAKE ALLEN DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-2944
Practice Address - Country:US
Practice Address - Phone:561-306-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician