Provider Demographics
NPI:1427607357
Name:MYATT, ALISSA MEADOW (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:MEADOW
Last Name:MYATT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15182
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32035-3104
Mailing Address - Country:US
Mailing Address - Phone:805-559-8889
Mailing Address - Fax:
Practice Address - Street 1:49 MARSH CREEK RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-6414
Practice Address - Country:US
Practice Address - Phone:805-559-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW209951041C0700X
CALCS18282104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker