Provider Demographics
NPI:1720467970
Name:WIDDEKIND, HOLLIS (LCSW)
Entity Type:Individual
Prefix:
First Name:HOLLIS
Middle Name:
Last Name:WIDDEKIND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EUBANKS CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-1903
Mailing Address - Country:US
Mailing Address - Phone:954-663-2475
Mailing Address - Fax:
Practice Address - Street 1:621 NW 53RD ST STE 125
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-8236
Practice Address - Country:US
Practice Address - Phone:954-663-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 127791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical