Healthcare Provider Details

I. General information

NPI: 1053578179
Provider Name (Legal Business Name): AMY L. WIDENBAUM, LMSW, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23800 ORCHARD LAKE RD STE 215
FARMINGTON HILLS MI
48336-2562
US

IV. Provider business mailing address

23800 ORCHARD LAKE RD STE 215
FARMINGTON HILLS MI
48336-2562
US

V. Phone/Fax

Practice location:
  • Phone: 248-568-9680
  • Fax: 248-493-6212
Mailing address:
  • Phone: 248-568-9680
  • Fax: 248-493-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801066237
License Number StateMI

VIII. Authorized Official

Name: AMY LYNN WIDENBAUM
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 248-568-9680