MEDICARE: MRS. GAIL RENE MIELKE M.A. CCC-SLP

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	235Z00000X	Speech-Language Pathologist	06129	MD

General Provider Information

NPI Number	:	1346719382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GAIL RENE MIELKE M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	10910 CLARKSVILLE PIKE
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-6106
Country	:	US
Telephone Number	:	410-313-6600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4691 TEN OAKS RD
Second Line	:
City	:	DAYTON
State	:	MD
Zip	:	21036-1126
Country	:	US
Telephone Number	:	410-313-1742
Fax Number	:

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

Provider Enumeration Date	:	11/20/2018
Last Update Date	:	11/20/2018

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