Provider Demographics
NPI:1750445185
Name:GOELLER, MYRA (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:
Last Name:GOELLER
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SEVENTH AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1146
Mailing Address - Country:US
Mailing Address - Phone:516-676-1722
Mailing Address - Fax:516-676-4250
Practice Address - Street 1:233 SEVENTH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5747
Practice Address - Country:US
Practice Address - Phone:516-676-1722
Practice Address - Fax:516-676-4250
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6674101YA0400X
NYR049409-2101YM0800X
NYR0494091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7482515OtherGHI-BMP CITY OF NY
NY156994OtherVALUE OPTIONS
NY2108404OtherCIGNA BEHAVIORAL HEALTH
NY02455392Medicaid
NY100674POtherHIP
NY049409-B37OtherHEALTHFIRST
NY156994OtherVALUE OPTIONS