Provider Demographics
NPI:1225224827
Name:WEST, MYRA DORENE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MYRA
Middle Name:DORENE
Last Name:WEST
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S CENTRAL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2866
Mailing Address - Country:US
Mailing Address - Phone:715-721-6916
Mailing Address - Fax:
Practice Address - Street 1:211 S CENTRAL AVE STE 500
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-2866
Practice Address - Country:US
Practice Address - Phone:715-721-6916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007264103TC2200X
WI3467-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent