MEDICARE: MS. COLLEEN MIELKE MSW, LCSW

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	LCS24357	CA

General Provider Information

NPI Number	:	1134250327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. COLLEEN MIELKE MSW, LCSW

Provider Business Mailing Address
First Line	:	10811 WASHINGTON BLVD
Second Line	:	SUITE 280-4
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3659
Country	:	US
Telephone Number	:	310-904-2095
Fax Number	:

Provider Business Practice Location Address
First Line	:	10811 WASHINGTON BLVD
Second Line	:	SUITE 280-4
City	:	CULVER CITY
State	:	CA
Zip	:	90232-3659
Country	:	US
Telephone Number	:	310-904-2095
Fax Number	:

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	04/26/2010

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