Provider Demographics
NPI:1669641361
Name:MIATKE, TERA MARIE
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:MARIE
Last Name:MIATKE
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 1:3230 TURQUOIS WAY
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9390
Mailing Address - Country:US
Mailing Address - Phone:309-827-5020
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:309-829-6808
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical