Provider Demographics
NPI:1659331460
Name:MYERS, DEROSSET JR (PHD)
Entity Type:Individual
Prefix:
First Name:DEROSSET
Middle Name:
Last Name:MYERS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8003
Mailing Address - Country:US
Mailing Address - Phone:803-255-3400
Mailing Address - Fax:803-255-3420
Practice Address - Street 1:15 MEDICAL PARK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8003
Practice Address - Country:US
Practice Address - Phone:803-255-3400
Practice Address - Fax:803-255-3420
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC431103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0046Medicaid
SCGP0720Medicaid
Q31968Medicare UPIN
SCQ319684411Medicare PIN
Q319684411Medicare ID - Type Unspecified