Provider Demographics
NPI:1134250327
Name:MIELKE, COLLEEN (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:MIELKE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 WASHINGTON BLVD
Mailing Address - Street 2:SUITE 280-4
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3659
Mailing Address - Country:US
Mailing Address - Phone:310-904-2095
Mailing Address - Fax:
Practice Address - Street 1:10811 WASHINGTON BLVD
Practice Address - Street 2:SUITE 280-4
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3659
Practice Address - Country:US
Practice Address - Phone:310-904-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS243571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical