Basic Information
| Provider Information | |||||||||
| NPI: | 1164845848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIELKE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FLEETWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195221323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109440445 | ||||||||
| FaxNumber: | 6109448834 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | WELLSBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169011737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707230620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.