Provider Demographics
NPI:1720290497
Name:WIDEMAN, JOSEPH R (MS, CAC, LPC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:WIDEMAN
Suffix:
Gender:M
Credentials:MS, CAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 PITTSTON AVE.
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505
Mailing Address - Country:US
Mailing Address - Phone:570-344-2676
Mailing Address - Fax:570-344-6794
Practice Address - Street 1:1002 PITTSTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-4169
Practice Address - Country:US
Practice Address - Phone:570-344-2676
Practice Address - Fax:570-344-6794
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional