Provider Demographics
NPI:1053695684
Name:MIDDLETON, SUE GAIL (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:SUE
Middle Name:GAIL
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:MISS
Other - First Name:SUE
Other - Middle Name:GAIL
Other - Last Name:BURCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1355 N UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-221-0223
Mailing Address - Fax:801-221-0291
Practice Address - Street 1:1355 N UNIVERSITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-221-0223
Practice Address - Fax:801-221-0291
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139789-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical