Provider Demographics
NPI:1497999270
Name:MIDDAUGH, PENNY JEAN (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:JEAN
Last Name:MIDDAUGH
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:MRS
Other - First Name:PENNY
Other - Middle Name:JEAN
Other - Last Name:STANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:43 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-1993
Mailing Address - Country:US
Mailing Address - Phone:513-947-7011
Mailing Address - Fax:513-947-7000
Practice Address - Street 1:43 E MAIN ST
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1993
Practice Address - Country:US
Practice Address - Phone:513-947-7011
Practice Address - Fax:513-947-7000
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0005944 SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2011322Medicare PIN