Provider Demographics
NPI:1750481354
Name:TIERNEY, SHANNONN MARIE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SHANNONN
Middle Name:MARIE
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6007
Mailing Address - Country:US
Mailing Address - Phone:360-379-5339
Mailing Address - Fax:360-379-5339
Practice Address - Street 1:530 19TH ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6007
Practice Address - Country:US
Practice Address - Phone:360-379-5339
Practice Address - Fax:360-379-5339
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000079151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical