Provider Demographics
NPI:1134424336
Name:SHAFFER, TIERNEY (LCSW)
Entity type:Individual
Prefix:
First Name:TIERNEY
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WAYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-6005
Mailing Address - Country:US
Mailing Address - Phone:303-241-1017
Mailing Address - Fax:
Practice Address - Street 1:19 WAYSIDE LN
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-6005
Practice Address - Country:US
Practice Address - Phone:303-241-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW177681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3032411017Medicaid