Provider Demographics
NPI:1265149686
Name:SUCKRA, MYESHA ADESHA
Entity type:Individual
Prefix:
First Name:MYESHA
Middle Name:ADESHA
Last Name:SUCKRA
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 1:5400 NW 39TH AVE APT CC278
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6956
Mailing Address - Country:US
Mailing Address - Phone:772-418-0936
Mailing Address - Fax:
Practice Address - Street 1:4881 NW 8TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4582
Practice Address - Country:US
Practice Address - Phone:352-474-8882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health