Basic Information
| Provider Information | |||||||||
| NPI: | 1083805097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLEBROOK | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3282 ADELINE ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947032439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815280 | ||||||||
| FaxNumber: | 5109815255 | ||||||||
| Practice Location | |||||||||
| Address1: | 3282 ADELINE ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947032439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5109815280 | ||||||||
| FaxNumber: | 5109815255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 08/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.