Provider Demographics
NPI:1447459474
Name:MIERKE, RAE ANN (MS)
Entity type:Individual
Prefix:
First Name:RAE
Middle Name:ANN
Last Name:MIERKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:RAE
Other - Middle Name:ANN
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:333 SUNRISE AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2716 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818
Practice Address - Country:US
Practice Address - Phone:916-690-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93710106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist