Provider Demographics
NPI:1740226786
Name:MYERS, KATHLEEN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4819
Mailing Address - Country:US
Mailing Address - Phone:203-378-4514
Mailing Address - Fax:203-378-0443
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4819
Practice Address - Country:US
Practice Address - Phone:203-378-4514
Practice Address - Fax:230-378-0443
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1119931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P23800Medicare ID - Type Unspecified