Provider Demographics
NPI:1417543745
Name:MIELKE, MEAGAN PHAM
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:PHAM
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 1:15895 JACKSON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-6803
Mailing Address - Country:US
Mailing Address - Phone:408-702-7955
Mailing Address - Fax:
Practice Address - Street 1:16275 MONTEREY RD
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-5466
Practice Address - Country:US
Practice Address - Phone:408-778-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8595101YM0800X
CA122038106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health