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General NPI Number Information
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NPI Number | 1992599641
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Entity Type | Individual
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Provider Name | DAVID WIDOM LCSW
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Gender | Male
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Dates
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Enumeration Date | 04/08/2025
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 438 W LAS TUNAS DR
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City | SAN GABRIEL
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State | CA
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Zip | 91776-1216
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Country | US
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Telephone | 626-300-7300
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Fax |
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Provider Business Mailing Address
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Address Line | 1050 INDIANA AVE
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City | VENICE
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State | CA
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Zip | 90291-2876
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Country | US
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Telephone | 310-678-1812
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS18058
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License Number State | CA
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