Provider Demographics
NPI:1114994340
Name:MIELKE, SUSAN M (DMIN LCPC (IL))
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:MIELKE
Suffix:
Gender:F
Credentials:DMIN LCPC (IL)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 HENRY ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6326
Mailing Address - Country:US
Mailing Address - Phone:618-474-7300
Mailing Address - Fax:618-462-8146
Practice Address - Street 1:307 HENRY ST
Practice Address - Street 2:SUITE 308
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6326
Practice Address - Country:US
Practice Address - Phone:618-474-7300
Practice Address - Fax:618-462-8146
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional