Basic Information
| Provider Information | |||||||||
| NPI: | 1912120387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDMAYER | ||||||||
| FirstName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281055 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281055 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 002691 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.