Provider Demographics
NPI:1063133189
Name:WAXWING PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:WAXWING PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SUPERVISOR, THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMFT, LMFT
Authorized Official - Phone:319-382-0751
Mailing Address - Street 1:700 16TH ST NE STE 206
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4665
Mailing Address - Country:US
Mailing Address - Phone:319-382-0751
Mailing Address - Fax:
Practice Address - Street 1:700 16TH ST NE STE 206
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4665
Practice Address - Country:US
Practice Address - Phone:319-382-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty