Provider Demographics
NPI:1760004907
Name:MIELKE, BRANDON ROBERT PETER (BA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROBERT PETER
Last Name:MIELKE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 MILTON RD
Mailing Address - Street 2:
Mailing Address - City:ALANSON
Mailing Address - State:MI
Mailing Address - Zip Code:49706-9507
Mailing Address - Country:US
Mailing Address - Phone:586-337-5800
Mailing Address - Fax:
Practice Address - Street 1:704 EMMET ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2910
Practice Address - Country:US
Practice Address - Phone:231-347-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0240037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)