Provider Demographics
NPI:1679719959
Name:MYRE, TAMERA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:ANN
Last Name:MYRE
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 1:201 S GARNETT RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-1805
Mailing Address - Country:US
Mailing Address - Phone:180-092-7397
Mailing Address - Fax:918-437-8016
Practice Address - Street 1:201 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1805
Practice Address - Country:US
Practice Address - Phone:180-092-7397
Practice Address - Fax:918-437-8016
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200311180AMedicaid