Provider Demographics
NPI:1790819100
Name:MIDDLEBROOKS, TERRYN MARIE (MS)
Entity Type:Individual
Prefix:MS
First Name:TERRYN
Middle Name:MARIE
Last Name:MIDDLEBROOKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:TERRYN
Other - Middle Name:MARIE
Other - Last Name:ORMONDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2130 PROFESSIONAL DR STE 240
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3780
Mailing Address - Country:US
Mailing Address - Phone:916-678-1238
Mailing Address - Fax:
Practice Address - Street 1:2130 PROFESSIONAL DR STE 240
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3780
Practice Address - Country:US
Practice Address - Phone:916-678-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71629106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator