Healthcare Provider Details

I. General information

NPI: 1427952084
Provider Name (Legal Business Name): AIDAN JARED WIGHTMAN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

7555 MAIN RD
MATTITUCK NY
11952-1516
US

IV. Provider business mailing address

98 WATERVIEW DR
SOUND BEACH NY
11789-1034
US

V. Phone/Fax

Practice location:
  • Phone: 631-298-8642
  • Fax:
Mailing address:
  • Phone: 631-697-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number133311
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: