Healthcare Provider Details

I. General information

NPI: 1679806533
Provider Name (Legal Business Name): MICHELLE RENEE WIDOWS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE RENEE WIDOWS MOORE PHD

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CITY BLVD STE B
WAYCROSS GA
31501-8016
US

IV. Provider business mailing address

515 CITY BLVD STE B
WAYCROSS GA
31501-8016
US

V. Phone/Fax

Practice location:
  • Phone: 912-249-4400
  • Fax: 912-279-4448
Mailing address:
  • Phone: 912-249-4400
  • Fax: 912-279-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3155
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6699
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3155
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPY669
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number3155
License Number StateCO
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6699
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: