Provider Demographics
NPI:1396858825
Name:TIERNEY, MARINA CLARICE (PSYD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:CLARICE
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 E WEBSTER PL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4256
Mailing Address - Country:US
Mailing Address - Phone:414-964-9200
Mailing Address - Fax:
Practice Address - Street 1:2524 E WEBSTER PL
Practice Address - Street 2:SUITE 203
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4256
Practice Address - Country:US
Practice Address - Phone:414-964-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2459-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43576000Medicaid
WI43576000Medicaid