=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790590420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESE ADELE MIDDLETON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2535 US HIGHWAY 117 S
-----------------------------------------------------
City | SAINT HELENA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28425-7633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-200-9982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2535 US HIGHWAY 117 S
-----------------------------------------------------
City | SAINT HELENA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28425-7633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904011505
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C012117
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------