Provider Demographics
NPI:1497376388
Name:MYRIE, COLLEEN MARIAN (LSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIAN
Last Name:MYRIE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CLIFTON AVE APT D1812
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1855
Mailing Address - Country:US
Mailing Address - Phone:917-224-2691
Mailing Address - Fax:
Practice Address - Street 1:25 CLIFTON AVE APT D1812
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-1855
Practice Address - Country:US
Practice Address - Phone:917-224-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06562900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SL06562900OtherBOARD LICENSE