Healthcare Provider Details

I. General information

NPI: 1265355242
Provider Name (Legal Business Name): BACK 2 YOUR ROOTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 STATION ST
CLOVER SC
29710-4077
US

IV. Provider business mailing address

301 S MCDOWELL ST STE 125-2517
CHARLOTTE NC
28204-2623
US

V. Phone/Fax

Practice location:
  • Phone: 704-936-8113
  • Fax:
Mailing address:
  • Phone: 704-936-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: TIERRA KIRKLAND
Title or Position: FOUNDER/OWNER
Credential: LCMHCS, LPCS
Phone: 704-936-8113