Healthcare Provider Details

I. General information

NPI: 1760387088
Provider Name (Legal Business Name): THEO JAMES WIDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 HOLCOMB AVE APT 202
URBANDALE IA
50323-2795
US

IV. Provider business mailing address

14300 HOLCOMB AVE APT 202
URBANDALE IA
50323-2795
US

V. Phone/Fax

Practice location:
  • Phone: 641-757-7302
  • Fax:
Mailing address:
  • Phone: 641-757-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: