Provider Demographics
NPI:1114023264
Name:AMBAR MIDDLEMAN, ADINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ADINA
Middle Name:
Last Name:AMBAR MIDDLEMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 WAKE FOREST RD.
Mailing Address - Street 2:STE. 304
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7323
Mailing Address - Country:US
Mailing Address - Phone:919-612-0706
Mailing Address - Fax:919-790-2361
Practice Address - Street 1:4109 WAKE FOREST RD.
Practice Address - Street 2:STE. 304
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7323
Practice Address - Country:US
Practice Address - Phone:919-612-0706
Practice Address - Fax:919-790-2361
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0050341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003705Medicaid
NC282232OtherCOMPSYCH
NC140MVOtherHEALTH CHOICE NC STATE