Provider Demographics
NPI:1730222639
Name:ZIELKE, ALFRED R (LICSW, PHD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:R
Last Name:ZIELKE
Suffix:
Gender:M
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3606
Mailing Address - Country:US
Mailing Address - Phone:781-395-7466
Mailing Address - Fax:
Practice Address - Street 1:397 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3606
Practice Address - Country:US
Practice Address - Phone:781-395-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW #1072871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO6628OtherBLUE CROSS BLUE SHIELD MA
MAPO6628Medicare ID - Type Unspecified