Provider Demographics
NPI:1043464530
Name:WOLFLEY, MYRA LYNN
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:LYNN
Last Name:WOLFLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:LYNN
Other - Last Name:DERMYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18202 N 35TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2405
Mailing Address - Country:US
Mailing Address - Phone:602-439-4390
Mailing Address - Fax:602-439-4390
Practice Address - Street 1:18202 N 35TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-2405
Practice Address - Country:US
Practice Address - Phone:602-439-4390
Practice Address - Fax:602-439-4390
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional