Provider Demographics
NPI:1851779680
Name:MYTON, PHILLIP (LCSW)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MYTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 EXECUTIVE CT STE 302
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4551
Mailing Address - Country:US
Mailing Address - Phone:501-744-4242
Mailing Address - Fax:
Practice Address - Street 1:204 EXECUTIVE CT STE 302
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4551
Practice Address - Country:US
Practice Address - Phone:501-744-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X, 390200000X
AR8052-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program