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 1:1345 MONROE AVE NW STE 234
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4692
Mailing Address - Country:US
Mailing Address - Phone:616-420-1060
Mailing Address - Fax:616-682-6992
Practice Address - Street 1:1345 MONROE AVE NW STE 234
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4692
Practice Address - Country:US
Practice Address - Phone:616-420-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2022-07-16
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