MEDICARE: TIFFANNI MIELKE LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801090187	MI

General Provider Information

NPI Number	:	1083151427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANNI MIELKE LMSW

Provider Business Mailing Address
First Line	:	54320 COUNTY ROAD 388
Second Line	:
City	:	GRAND JCT
State	:	MI
Zip	:	49056-9272
Country	:	US
Telephone Number	:	269-363-2302
Fax Number	:

Provider Business Practice Location Address
First Line	:	54320 COUNTY ROAD 388
Second Line	:
City	:	GRAND JUNCTION
State	:	MI
Zip	:	49056-9272
Country	:	US
Telephone Number	:	269-363-2302
Fax Number	:	269-434-6405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	07/19/2019

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