Provider Demographics
NPI:1225224827
Name:WEST, MYRA DORENE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:DORENE
Last Name:WEST
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 1:200 LAKEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1718
Mailing Address - Country:US
Mailing Address - Phone:708-481-9799
Mailing Address - Fax:708-481-9951
Practice Address - Street 1:200 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1718
Practice Address - Country:US
Practice Address - Phone:708-481-9799
Practice Address - Fax:708-481-9951
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007264103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent