Provider Demographics
NPI:1699338863
Name:MIDDAUGH, STEPHANIE R (PSYD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:MIDDAUGH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1736 E GAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8712
Mailing Address - Country:US
Mailing Address - Phone:602-708-6338
Mailing Address - Fax:
Practice Address - Street 1:3115 S PRICE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-3544
Practice Address - Country:US
Practice Address - Phone:480-855-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005100103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist