Provider Demographics
NPI:1760901995
Name:TALMADGE, TIERNEY NICHOLE (ACMHC)
Entity Type:Individual
Prefix:
First Name:TIERNEY
Middle Name:NICHOLE
Last Name:TALMADGE
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 W ROLLING RIVER RD
Mailing Address - Street 2:
Mailing Address - City:S SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7920
Mailing Address - Country:US
Mailing Address - Phone:801-702-6652
Mailing Address - Fax:
Practice Address - Street 1:7601 S REDWOOD RD BLDG E
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10387308-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10387308-6009OtherDOPL LICENSE NUMBER