Provider Demographics
NPI:1710084801
Name:MEANS, MYRTLE CHARISSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRTLE
Middle Name:CHARISSE
Last Name:MEANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11285 ELKINS RD STE D3
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5835
Mailing Address - Country:US
Mailing Address - Phone:313-574-6616
Mailing Address - Fax:
Practice Address - Street 1:23003 GREATER MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1965
Practice Address - Country:US
Practice Address - Phone:313-574-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011889103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68OE017280OtherBCBS
MI68OE017280OtherBCBS