Provider Demographics
NPI:1740891282
Name:WIDMANN, GERARD DAVID (PSYD)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:DAVID
Last Name:WIDMANN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7410264
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0264
Mailing Address - Country:US
Mailing Address - Phone:815-942-6323
Mailing Address - Fax:779-210-5541
Practice Address - Street 1:640 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6603
Practice Address - Country:US
Practice Address - Phone:815-942-6323
Practice Address - Fax:779-210-5541
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010323103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical