Basic Information
| Provider Information | |||||||||
| NPI: | 1447460480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDAGH | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5208183630 | ||||||||
| Practice Location | |||||||||
| Address1: | 13395 N MARANA MAIN ST | ||||||||
| Address2: | BLDG B | ||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856537008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206821091 | ||||||||
| FaxNumber: | 5206824132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-4049 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 642133 | 05 | AZ | MEDICAID |