Basic Information
| Provider Information | |||||||||
| NPI: | 1417004862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLIN | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AT/ATC, CSCS, CES | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MIDDLIN | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, NCC, LLPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2040 LEITCH RD | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482201510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482665616 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Practice Location | |||||||||
| Address1: | 39425 GARFIELD RD STE 23 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482665616 | ||||||||
| FaxNumber: | 2486053525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | L148244 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 2255A2300X | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 101Y00000X | 6401014131 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.