Provider Demographics
NPI:1578621009
Name:MIDDLETON, DEBORAH M
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:M
Other - Last Name:BOMKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1424 BOYD LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-2813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3405 W. TRUMAN, 101
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5861
Practice Address - Country:US
Practice Address - Phone:573-864-7868
Practice Address - Fax:573-864-7868
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002265104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493615124Medicaid