Provider Demographics
NPI:1346757762
Name:YOUNGBLOOD-FIELD, TIERRA
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:YOUNGBLOOD-FIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIERRA
Other - Middle Name:
Other - Last Name:YOUNGBLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-336-3909
Mailing Address - Fax:616-336-8830
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-336-3909
Practice Address - Fax:616-336-8830
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006746106H00000X
MI4101007120106H00000X
MI6401017826101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346757762Medicaid