Basic Information
| Provider Information | |||||||||
| NPI: | 1902271364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIDEMAN | ||||||||
| FirstName: | BILLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, NCC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12005 E 470 RD | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183420770 | ||||||||
| FaxNumber: | 9183420087 | ||||||||
| Practice Location | |||||||||
| Address1: | 12005 E 470 RD | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183420770 | ||||||||
| FaxNumber: | 9183420087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.