Basic Information
| Provider Information | |||||||||
| NPI: | 1790239804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | MARIAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 S BURDICK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693813700 | ||||||||
| FaxNumber: | 2693813810 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 S BURDICK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693813700 | ||||||||
| FaxNumber: | 2693813810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2016 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801099479 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1790239804 | 05 | MI | MEDICAID |