Provider Demographics
NPI:1386707859
Name:MIDDLEBROOK, MICAH (MFT)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MIDDLEBROOK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8009
Mailing Address - Street 2:
Mailing Address - City:LOMA RICA
Mailing Address - State:CA
Mailing Address - Zip Code:95901-8401
Mailing Address - Country:US
Mailing Address - Phone:530-301-1384
Mailing Address - Fax:
Practice Address - Street 1:4643 FRUITLAND RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-8706
Practice Address - Country:US
Practice Address - Phone:530-301-1384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist