Healthcare Provider Details

I. General information

NPI: 1265414379
Provider Name (Legal Business Name): BETH WIDZOWSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 WANTAGH AVE SOUTH SHORE COUNSELING
WANTAGH NY
11793-2216
US

IV. Provider business mailing address

33 RANDY LN
PLAINVIEW NY
11803-3942
US

V. Phone/Fax

Practice location:
  • Phone: 516-785-0323
  • Fax: 516-785-6026
Mailing address:
  • Phone: 516-938-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: