Provider Demographics
NPI:1932607199
Name:MYERS, ANGELA MAKEBA (LISCW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MAKEBA
Last Name:MYERS
Suffix:
Gender:F
Credentials:LISCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 DUNLAP ST N STE 736
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4205
Mailing Address - Country:US
Mailing Address - Phone:612-289-5656
Mailing Address - Fax:651-925-0278
Practice Address - Street 1:393 DUNLAP ST N STE 736
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4205
Practice Address - Country:US
Practice Address - Phone:612-289-5656
Practice Address - Fax:651-925-0278
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN243911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN46-3824598OtherTAX ID
MN1780011510OtherNPI