Provider Demographics
NPI:1114136090
Name:MIDDLETON, TAMARA (CMHC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 521207
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84152-1207
Mailing Address - Country:US
Mailing Address - Phone:801-983-5540
Mailing Address - Fax:801-983-5542
Practice Address - Street 1:3195 S MAIN ST STE 180
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3790
Practice Address - Country:US
Practice Address - Phone:801-983-5540
Practice Address - Fax:801-983-5542
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5459608-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5459608-3503OtherSTATE LICENSE