Provider Demographics
NPI:1538170618
Name:MIDDLETON, SUSAN C (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:MIDDLETON
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 1:15 SW COLORADO AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1150
Mailing Address - Country:US
Mailing Address - Phone:541-390-8443
Mailing Address - Fax:541-728-0436
Practice Address - Street 1:15 SW COLORADO AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1150
Practice Address - Country:US
Practice Address - Phone:541-390-8443
Practice Address - Fax:541-728-0436
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL35981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131661Medicare ID - Type Unspecified