Healthcare Provider Details

I. General information

NPI: 1063133189
Provider Name (Legal Business Name): WAXWING PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 16TH ST NE STE 206
CEDAR RAPIDS IA
52402-4665
US

IV. Provider business mailing address

700 16TH ST NE STE 206
CEDAR RAPIDS IA
52402-4665
US

V. Phone/Fax

Practice location:
  • Phone: 319-382-0751
  • Fax:
Mailing address:
  • Phone: 319-382-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ANTHONY J. MIELKE
Title or Position: OWNER, SUPERVISOR, THERAPIST
Credential: DMFT, LMFT
Phone: 319-382-0751