1871537753 NPI number — MRS. SUSAN MARIE TIELKER-SHARPE LCSW LMFT ACSW

Table of content: MRS. SUSAN MARIE TIELKER-SHARPE LCSW LMFT ACSW (NPI 1871537753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871537753 NPI number — MRS. SUSAN MARIE TIELKER-SHARPE LCSW LMFT ACSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIELKER-SHARPE
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW LMFT ACSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIELKER
Provider Other First Name:
SUSAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW LMFT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871537753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4656 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
SUITE 285
Provider Business Mailing Address City Name:
FT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-422-9372
Provider Business Mailing Address Fax Number:
260-422-0843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4656 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 285
Provider Business Practice Location Address City Name:
FT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-9372
Provider Business Practice Location Address Fax Number:
260-422-0843
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  35000408ALMFT , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 34000886A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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