Provider Demographics
NPI:1861101768
Name:TIERNEY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718-1046
Mailing Address - Country:US
Mailing Address - Phone:732-687-9796
Mailing Address - Fax:
Practice Address - Street 1:25 W PARK AVE
Practice Address - Street 2:
Practice Address - City:BELFORD
Practice Address - State:NJ
Practice Address - Zip Code:07718-1046
Practice Address - Country:US
Practice Address - Phone:732-687-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00361200101YA0400X
NJ37AC00562300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty