Provider Demographics
NPI:1245255710
Name:MYERS, MARK A (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:MYERS
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 1:300 MEMORIAL DR 200
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6273
Mailing Address - Country:US
Mailing Address - Phone:815-308-3368
Mailing Address - Fax:815-356-7044
Practice Address - Street 1:300 MEMORIAL DR 200
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6273
Practice Address - Country:US
Practice Address - Phone:815-308-3368
Practice Address - Fax:815-356-7044
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490027051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical