Provider Demographics
NPI:1366607533
Name:CONKLIN, REBECCA NICOLE
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:NICOLE
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MARYLAND CT NE APT 17
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2154
Mailing Address - Country:US
Mailing Address - Phone:616-634-6909
Mailing Address - Fax:
Practice Address - Street 1:901 EASTERN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1201
Practice Address - Country:US
Practice Address - Phone:616-224-7472
Practice Address - Fax:616-224-7619
Is Sole Proprietor?:No
Enumeration Date:2008-07-27
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker