Provider Demographics
NPI:1700131471
Name:MIDDLETON, TINA (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N 1700 W
Mailing Address - Street 2:# 37
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700W 2700N
Practice Address - Street 2:# 37
Practice Address - City:PLEASANT VIEW
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-389-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT207323-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist