Healthcare Provider Details

I. General information

NPI: 1457302671
Provider Name (Legal Business Name): ANDREA TIERNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7912 E MENTON AVE
ANAHEIM CA
92808-1559
US

IV. Provider business mailing address

7912 E MENTON AVE
ANAHEIM CA
92808-1559
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-4292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: