Provider Demographics
NPI:1356466197
Name:TIERNEY, DOREEN ANNE
Entity Type:Individual
Prefix:MISS
First Name:DOREEN
Middle Name:ANNE
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 1:35 STATE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6369
Mailing Address - Country:US
Mailing Address - Phone:507-497-3790
Mailing Address - Fax:
Practice Address - Street 1:35 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6368
Practice Address - Country:US
Practice Address - Phone:507-497-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6195235Z00000X
CT003440235Z00000X
RISP00543235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist