Basic Information
| Provider Information | |||||||||
| NPI: | 1952433138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDENER | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | NALL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5808 SAGE BRUSH TRL | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274092732 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 318 TURNERSBURG HWY | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286252798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048731114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1299 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6107166 | 05 | NC | MEDICAID |