Provider Demographics
NPI:1710197843
Name:MYRON, ELMER GEORGE (LBSW, LISAC)
Entity Type:Individual
Prefix:MR
First Name:ELMER
Middle Name:GEORGE
Last Name:MYRON
Suffix:
Gender:M
Credentials:LBSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 W COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2970
Mailing Address - Country:US
Mailing Address - Phone:602-481-6717
Mailing Address - Fax:602-279-5393
Practice Address - Street 1:4041 N. CENTRAL AVE
Practice Address - Street 2:BUILDING C
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3133
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:602-279-5393
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11597101YA0400X
AZ4125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ910209Medicaid