Provider Demographics
NPI:1730375338
Name:WIGGINS, JUDITH ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ELLEN
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 75TH ST W UNIT 117
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5856
Mailing Address - Country:US
Mailing Address - Phone:815-210-3348
Mailing Address - Fax:
Practice Address - Street 1:1753 RINGLING BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-6874
Practice Address - Country:US
Practice Address - Phone:941-366-2224
Practice Address - Fax:941-366-2982
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW130391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11788409OtherCAQH PROVIDER ID
FL001870500Medicaid