Basic Information
| Provider Information | |||||||||
| NPI: | 1083202790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 NALL AVE | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319947449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 912 SUMMERTOWN HWY | ||||||||
| Address2: | |||||||||
| City: | HOHENWALD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384625703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882914357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2021 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.