Healthcare Provider Details

I. General information

NPI: 1598124257
Provider Name (Legal Business Name): MARY MIDDLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E STATE ST STE 624
MASON CITY IA
50401-3327
US

IV. Provider business mailing address

103 E STATE ST STE 624
MASON CITY IA
50401-3327
US

V. Phone/Fax

Practice location:
  • Phone: 641-450-6007
  • Fax:
Mailing address:
  • Phone: 641-450-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number115445
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11342
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number115445
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: