Basic Information
Provider Information
NPI: 1154410793
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MYERS
FirstName: DORETHA
MiddleName: JEAN
NamePrefix: MS.
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 497
Address2:  
City: AUGUSTA
State: AR
PostalCode: 720060497
CountryCode: US
TelephoneNumber: 8703472534
FaxNumber:  
Practice Location
Address1: 1028 N MISSOURI ST STE 6
Address2:  
City: WEST MEMPHIS
State: AR
PostalCode: 723012600
CountryCode: US
TelephoneNumber: 8704000263
FaxNumber: 8704000293
Other Information
ProviderEnumerationDate: 10/12/2006
LastUpdateDate: 07/22/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/22/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X2625CARY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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