Provider Demographics
NPI:1679692073
Name:MIDDLEBROOKS, MARK T (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:MIDDLEBROOKS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W MAIN ST
Mailing Address - Street 2:#102
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3771
Mailing Address - Country:US
Mailing Address - Phone:281-332-4396
Mailing Address - Fax:
Practice Address - Street 1:614 W MAIN ST
Practice Address - Street 2:#102
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3771
Practice Address - Country:US
Practice Address - Phone:281-332-4396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S15TMedicare ID - Type Unspecified