Provider Demographics
NPI:1871914903
Name:ZIELKE, DESIREE (PHD)
Entity type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:
Last Name:ZIELKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 AMBER VALLEY PKWY S STE F
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8621
Mailing Address - Country:US
Mailing Address - Phone:701-551-1840
Mailing Address - Fax:701-551-1859
Practice Address - Street 1:4610 AMBER VALLEY PKWY S STE F
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8621
Practice Address - Country:US
Practice Address - Phone:701-551-1840
Practice Address - Fax:701-551-1859
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND489103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18937Medicaid
NDN719495Medicare PIN
NDN719494Medicare PIN