Basic Information
| Provider Information | |||||||||
| NPI: | 1518944271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 REILLY RD | ||||||||
| Address2: | MCXC COD CREDENTIALS | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078922 | ||||||||
| FaxNumber: | 9109076069 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG D 2004 MARION STREET | ||||||||
| Address2: | USASOC PAD | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3429 | OH | X | Behavioral Health & Social Service Providers | Psychologist | 103TA0400X | AD003542 | OH | X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
No ID Information.