Provider Demographics
NPI:1841522935
Name:MIDDLETON, TRISHA (DPT, CMPT)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:DPT, CMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 VAUGHN RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1848
Mailing Address - Country:US
Mailing Address - Phone:618-259-1100
Mailing Address - Fax:618-259-1101
Practice Address - Street 1:1138 VAUGHN RD
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1848
Practice Address - Country:US
Practice Address - Phone:618-259-1100
Practice Address - Fax:618-259-1101
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010001725225100000X
IL070018162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO991511004Medicare PIN
MO991509004Medicare PIN