MEDICARE: TIARA FENNELL LCMFT

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	LCM946	MD

General Provider Information

NPI Number	:	1619440633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIARA FENNELL LCMFT

Provider Business Mailing Address
First Line	:	1133 E WEST HWY APT 1120W
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-6824
Country	:	US
Telephone Number	:	910-284-7403
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 E WEST HWY APT 1120W
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-6824
Country	:	US
Telephone Number	:	910-284-7403
Fax Number	:

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

Provider Enumeration Date	:	01/03/2019
Last Update Date	:	06/25/2024

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