Provider Demographics
NPI:1790211134
Name:MYERS, LORI (LCSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MYERS
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 1:8658 AITKEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492
Mailing Address - Country:US
Mailing Address - Phone:315-323-7893
Mailing Address - Fax:315-866-3174
Practice Address - Street 1:8658 AITKEN AVE
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492-2609
Practice Address - Country:US
Practice Address - Phone:315-323-7893
Practice Address - Fax:315-748-5367
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096707-1104100000X
NY0880651041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004325146Medicaid