MEDICARE: TIERRA YVETTE SEIDLE

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1629937743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIERRA YVETTE SEIDLE

Provider Business Mailing Address
First Line	:	790 PARK AVE
Second Line	:
City	:	HUNTINGTON
State	:	NY
Zip	:	11743-4516
Country	:	US
Telephone Number	:	631-427-3700
Fax Number	:

Provider Business Practice Location Address
First Line	:	5429 LARCHWOOD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19143-1421
Country	:	US
Telephone Number	:	267-252-1778
Fax Number	:

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

Provider Enumeration Date	:	01/16/2026
Last Update Date	:	01/16/2026

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