MEDICARE: ELIZABETH MIDDLETON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L4080	OR
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1639376601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH MIDDLETON LCSW

Provider Business Mailing Address
First Line	:	2205 NE COLUMBIA BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-1930
Country	:	US
Telephone Number	:	503-988-3393
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 NE COLUMBIA BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-1930
Country	:	US
Telephone Number	:	503-988-3393
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	07/23/2013

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