Provider Demographics
NPI:1457599227
Name:PETERSON-WEIMANN, MYRNA ALVAREZ (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:ALVAREZ
Last Name:PETERSON-WEIMANN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 236292
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32923-6292
Mailing Address - Country:US
Mailing Address - Phone:321-427-5532
Mailing Address - Fax:321-250-7175
Practice Address - Street 1:1600 SARNO RD
Practice Address - Street 2:SUITE 119E
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-427-5532
Practice Address - Fax:321-250-7175
Is Sole Proprietor?:No
Enumeration Date:2009-02-01
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014374000Medicaid