Provider Demographics
NPI:1669105375
Name:MITKOV, SUSIE KATHERINE
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:KATHERINE
Last Name:MITKOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:KATHERINE
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:1521 S CUSHMAN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6203
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:907-459-3842
Practice Address - Street 1:1521 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6203
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:907-459-3842
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK5191621OtherDRIVER'S LICENSE