Provider Demographics
NPI:1962576173
Name:MIDDLETON, TRINA MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:TRINA
Middle Name:MARIE
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TIMBER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4233
Mailing Address - Country:US
Mailing Address - Phone:901-566-1002
Mailing Address - Fax:901-566-1951
Practice Address - Street 1:58 TIMBER CREEK DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4233
Practice Address - Country:US
Practice Address - Phone:901-566-1002
Practice Address - Fax:901-566-1951
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN907LSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3696333Medicare ID - Type Unspecified
621379190Medicare UPIN