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General NPI Number Information
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NPI Number | 1962049171
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Entity Type | Individual
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Provider Name | PRESTON JUDE MIDDLETON LCSW
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Gender | Male
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Dates
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Enumeration Date | 12/06/2019
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Last Update Date | 04/20/2023
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Provider Practice Location Address
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Address Line | 104 S FRONT AVE
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City | PRESTONSBURG
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State | KY
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Zip | 41653-1614
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Country | US
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Telephone | 606-886-8572
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Fax | 606-886-4433
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Provider Business Mailing Address
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Address Line | 829 E BYERS AVE
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City | OWENSBORO
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State | KY
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Zip | 42303-8820
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Country | US
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Telephone | 270-314-7851
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 9186
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 257831
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License Number State | KY
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