Provider Demographics
NPI:1619440633
Name:FENNELL, TIARA (LCMFT)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 E WEST HWY APT 1120W
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-6824
Mailing Address - Country:US
Mailing Address - Phone:910-284-7403
Mailing Address - Fax:
Practice Address - Street 1:1133 E WEST HWY APT 1120W
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-6824
Practice Address - Country:US
Practice Address - Phone:910-284-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist