Provider Demographics
NPI:1871249243
Name:CARPENTER, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:CARPENTER
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 1:24681 NORTHWESTERN HWY STE 2006
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2305
Mailing Address - Country:US
Mailing Address - Phone:248-579-3119
Mailing Address - Fax:
Practice Address - Street 1:24681 NORTHWESTERN HWY STE 2006
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2305
Practice Address - Country:US
Practice Address - Phone:248-579-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician