Provider Demographics
NPI:1811545304
Name:HULETT, MYRA J (CDCA)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:J
Last Name:HULETT
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-1134
Mailing Address - Country:US
Mailing Address - Phone:740-451-1551
Mailing Address - Fax:
Practice Address - Street 1:103 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1134
Practice Address - Country:US
Practice Address - Phone:740-451-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.172214101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator