Provider Demographics
NPI:1194609974
Name:MIDDLETON, TATANESHIA
Entity type:Individual
Prefix:
First Name:TATANESHIA
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5353 DRAKE LN
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1613
Practice Address - Country:US
Practice Address - Phone:773-580-1257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional