Provider Demographics
NPI:1275745770
Name:MEYERS, THERESA ADELE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ADELE
Last Name:MEYERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BARDNEY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9569
Mailing Address - Country:US
Mailing Address - Phone:585-729-4000
Mailing Address - Fax:585-223-2447
Practice Address - Street 1:15 BARDNEY CIRCLE
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-9569
Practice Address - Country:US
Practice Address - Phone:585-729-4000
Practice Address - Fax:585-223-2447
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046777-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646591Medicaid