Provider Demographics
NPI:1922488923
Name:MIDDLETON, WILLIAM WADE (LPT/PET CLINICIAN)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WADE
Last Name:MIDDLETON
Suffix:
Gender:M
Credentials:LPT/PET CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4809
Mailing Address - Country:US
Mailing Address - Phone:714-591-3856
Mailing Address - Fax:
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2609
Practice Address - Country:US
Practice Address - Phone:301-900-8210
Practice Address - Fax:310-900-8286
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26958101YM0800X, 167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA167G00000XOtherADDTAXONMY
CA1245227180Medicaid