Healthcare Provider Details

I. General information

NPI: 1235796509
Provider Name (Legal Business Name): KIMBER SUZANNE MIDDLETON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBER SUZANNE MCDANIEL

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 03/03/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 T J JACKSON DR STE D
FALLING WATERS WV
25419-4683
US

IV. Provider business mailing address

5635 MOUNT BRIAR RD
KEEDYSVILLE MD
21756-1529
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-6776
  • Fax:
Mailing address:
  • Phone: 239-222-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW12327
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberISW12327
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: