Provider Demographics
NPI:1003545898
Name:MIELKE, LAURA GOLDMAN
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:GOLDMAN
Last Name:MIELKE
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 1:4180 CARMICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-3600
Mailing Address - Country:US
Mailing Address - Phone:334-625-0121
Mailing Address - Fax:
Practice Address - Street 1:4180 CARMICHAEL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3600
Practice Address - Country:US
Practice Address - Phone:334-625-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist