Healthcare Provider Details

I. General information

NPI: 1558270579
Provider Name (Legal Business Name): TIERRA KONKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17111 G DR N
MARSHALL MI
49068-9641
US

IV. Provider business mailing address

13770 15 MILE RD
MARSHALL MI
49068-8503
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-5141
  • Fax:
Mailing address:
  • Phone: 269-986-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801118268
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: