Provider Demographics
NPI:1235896416
Name:MYERS, MICHELLE SUZANNE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUZANNE
Last Name:MYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 S 49TH ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-2292
Mailing Address - Country:US
Mailing Address - Phone:440-728-1147
Mailing Address - Fax:
Practice Address - Street 1:1200 W TABOR RD STE 100
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3019
Practice Address - Country:US
Practice Address - Phone:215-821-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health