Provider Demographics
NPI:1053578344
Name:TIERNEY, JULIA GRACE
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:GRACE
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 1:1157 W FARWELL AVE # 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3809
Mailing Address - Country:US
Mailing Address - Phone:415-420-8612
Mailing Address - Fax:
Practice Address - Street 1:1622 W COLUMBIA AVE APT 3N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4160
Practice Address - Country:US
Practice Address - Phone:415-420-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001410106H00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical