Provider Demographics
NPI:1396472783
Name:WIDDUP, TRENA ADAMS (SSW)
Entity type:Individual
Prefix:MS
First Name:TRENA
Middle Name:ADAMS
Last Name:WIDDUP
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 W IMPERIAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-1872
Mailing Address - Country:US
Mailing Address - Phone:801-556-0326
Mailing Address - Fax:
Practice Address - Street 1:5698 W GLEN EAGLE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-4013
Practice Address - Country:US
Practice Address - Phone:801-917-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health