Provider Demographics
NPI:1720350432
Name:CONKLIN, DIANA R (LLPC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:R
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9844 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:IRA
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2813
Mailing Address - Country:US
Mailing Address - Phone:586-716-7600
Mailing Address - Fax:586-716-7659
Practice Address - Street 1:9844 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:IRA
Practice Address - State:MI
Practice Address - Zip Code:48023-2813
Practice Address - Country:US
Practice Address - Phone:586-716-7600
Practice Address - Fax:586-716-7659
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health