Healthcare Provider Details

I. General information

NPI: 1417543745
Provider Name (Legal Business Name): MEAGAN PHAM MIELKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 YATELEY DR
VACAVILLE CA
95687-7953
US

IV. Provider business mailing address

15757 N 90TH PL APT 2016
SCOTTSDALE AZ
85260-2010
US

V. Phone/Fax

Practice location:
  • Phone: 530-688-6875
  • Fax:
Mailing address:
  • Phone: 408-702-7955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8595
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: