Provider Demographics
NPI:1821710237
Name:LIGHTFOOT, MYRA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:ELIZABETH
Last Name:LIGHTFOOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6494
Mailing Address - Country:US
Mailing Address - Phone:479-474-6444
Mailing Address - Fax:479-474-6446
Practice Address - Street 1:1109 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3363
Practice Address - Country:US
Practice Address - Phone:479-474-6444
Practice Address - Fax:479-474-6446
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician