Healthcare Provider Details

I. General information

NPI: 1841842333
Provider Name (Legal Business Name): CARL MICHAEL TIERNEY RMHCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2479 ALOMA AVE
WINTER PARK FL
32792-2541
US

IV. Provider business mailing address

3208 CRYSTAL PARK CT
LEAGUE CITY TX
77573-2248
US

V. Phone/Fax

Practice location:
  • Phone: 407-657-6692
  • Fax: 407-894-6010
Mailing address:
  • Phone: 407-587-6499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number94563
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH25112
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: