Healthcare Provider Details

I. General information

NPI: 1528986056
Provider Name (Legal Business Name): EDEN LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3857 BIRCH ST # 9105
NEWPORT BEACH CA
92660-2616
US

IV. Provider business mailing address

3857 BIRCH ST # 9105
NEWPORT BEACH CA
92660-2616
US

V. Phone/Fax

Practice location:
  • Phone: 949-688-3511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: NICOLE WIDMAN
Title or Position: OWNER
Credential: LCSW
Phone: 949-688-3511