Provider Demographics
NPI:1912363235
Name:MIDDLETON, RONIKA GORE (MED)
Entity Type:Individual
Prefix:
First Name:RONIKA
Middle Name:GORE
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 DICKERSON ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-1203
Mailing Address - Country:US
Mailing Address - Phone:864-888-7508
Mailing Address - Fax:
Practice Address - Street 1:103 DICKERSON ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-1203
Practice Address - Country:US
Practice Address - Phone:864-888-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC235245101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool