Provider Demographics
NPI:1417591090
Name:TIERNEY, KELLIE (LMT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3666
Mailing Address - Country:US
Mailing Address - Phone:516-520-1330
Mailing Address - Fax:
Practice Address - Street 1:376 FULTON ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3666
Practice Address - Country:US
Practice Address - Phone:631-741-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist