Provider Demographics
NPI:1790354041
Name:WIDDER, BROOKE CAMDEN (LPC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:CAMDEN
Last Name:WIDDER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 MARIETTA HWY STE 630-245
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-6755
Mailing Address - Country:US
Mailing Address - Phone:770-765-5965
Mailing Address - Fax:
Practice Address - Street 1:2002 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6346
Practice Address - Country:US
Practice Address - Phone:770-765-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012114101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health