MEDICARE: JULIA GRACE TIERNEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	166.001410	IL
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1053578344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA GRACE TIERNEY

Provider Business Mailing Address
First Line	:	1157 W FARWELL AVE # 2E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3809
Country	:	US
Telephone Number	:	415-420-8612
Fax Number	:

Provider Business Practice Location Address
First Line	:	1622 W COLUMBIA AVE APT 3N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4160
Country	:	US
Telephone Number	:	415-420-8612
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	11/17/2020

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