Provider Demographics
NPI:1982451142
Name:WIDGER, STACEY LIND
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LIND
Last Name:WIDGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 W WASHINGTON BLVD STE 134
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-8122
Mailing Address - Country:US
Mailing Address - Phone:310-306-8000
Mailing Address - Fax:
Practice Address - Street 1:321 N LARCHMONT BLVD STE 622
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6406
Practice Address - Country:US
Practice Address - Phone:310-344-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143643106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist