Provider Demographics
NPI:1871537753
Name:TIELKER-SHARPE, SUSAN MARIE (LCSW LMFT ACSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:TIELKER-SHARPE
Suffix:
Gender:F
Credentials:LCSW LMFT ACSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:TIELKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW LMFT
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 285
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-422-9372
Mailing Address - Fax:260-422-0843
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 285
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-422-9372
Practice Address - Fax:260-422-0843
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000408ALMFT106H00000X
IN34000886A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN150990000OtherMAGELLAN
IN000000299295OtherANTHEM
IN4352922OtherAETNA
IN150990000OtherMAGELLAN