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General NPI Number Information
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NPI Number | 1922488923
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Entity Type | Individual
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Provider Name | WILLIAM WADE MIDDLETON LPT/PET CLINICIAN
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Gender | Male
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 08/28/2019
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Provider Practice Location Address
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Address Line | 3630 E IMPERIAL HWY
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City | LYNWOOD
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State | CA
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Zip | 90262-2609
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Country | US
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Telephone | 301-900-8210
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Fax | 310-900-8286
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Provider Business Mailing Address
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Address Line | 919 OLIVE AVE
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92648-4809
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Country | US
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Telephone | 714-591-3856
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PT26958
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 167G00000X
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Taxonomy Name | Licensed Psychiatric Technician
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License Number | PT26958
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License Number State | CA
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