Provider Demographics
NPI:1306444286
Name:WIDECAN, MEREDITH
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:WIDECAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:
Other - Last Name:WIDECAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3162 HEMLOCK CT
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-1151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5740 DIBBLE RD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44048-9809
Practice Address - Country:US
Practice Address - Phone:440-224-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist