=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467114413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WIDMAYER AMBROISE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2021
-----------------------------------------------------
Last Update Date | 05/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 PARK ST APT 2
-----------------------------------------------------
City | ATTLEBORO
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02703-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-719-3922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 PARK ST APT 2
-----------------------------------------------------
City | ATTLEBORO
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02703-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-719-3922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225C00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171R00000X
-----------------------------------------------------
Taxonomy Name | Interpreter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225800000X
-----------------------------------------------------
Taxonomy Name | Recreation Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 372500000X
-----------------------------------------------------
Taxonomy Name | Chore Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 385HR2055X
-----------------------------------------------------
Taxonomy Name | Child Mental Illness Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------