Provider Demographics
NPI:1144995473
Name:WIDNALL, CHARNELL MARIE (MA, LMHC)
Entity type:Individual
Prefix:MRS
First Name:CHARNELL
Middle Name:MARIE
Last Name:WIDNALL
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3118 W BARCELONA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7210
Mailing Address - Country:US
Mailing Address - Phone:813-420-8256
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD STE 214
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2244
Practice Address - Country:US
Practice Address - Phone:813-553-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18278101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health