Provider Demographics
NPI:1912384009
Name:SMITH, TIERNEY HOUCK
Entity Type:Individual
Prefix:
First Name:TIERNEY
Middle Name:HOUCK
Last Name:SMITH
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 1:835 3RD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1352
Mailing Address - Country:US
Mailing Address - Phone:619-427-4661
Mailing Address - Fax:619-426-7849
Practice Address - Street 1:835 3RD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-427-4661
Practice Address - Fax:619-426-7849
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW67534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health