Provider Demographics
NPI:1164116562
Name:MIDDLETON, DANIELLE BROOKE (PTA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:BROOKE
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-8125
Mailing Address - Country:US
Mailing Address - Phone:937-245-0634
Mailing Address - Fax:
Practice Address - Street 1:1714 S GOLD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8951
Practice Address - Country:US
Practice Address - Phone:360-360-5532
Practice Address - Fax:564-999-5722
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA031102225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant