Provider Demographics
NPI:1083151427
Name:MIELKE, TIFFANNI (LMSW)
Entity Type:Individual
Prefix:
First Name:TIFFANNI
Middle Name:
Last Name:MIELKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54320 COUNTY ROAD 388
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:MI
Mailing Address - Zip Code:49056-9272
Mailing Address - Country:US
Mailing Address - Phone:269-363-2302
Mailing Address - Fax:
Practice Address - Street 1:54320 COUNTY ROAD 388
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:MI
Practice Address - Zip Code:49056-9272
Practice Address - Country:US
Practice Address - Phone:269-363-2302
Practice Address - Fax:269-434-6405
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010901871041C0700X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health