Provider Demographics
NPI:1952608911
Name:MYERS, WILLIAM M JR (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:M
Last Name:MYERS
Suffix:JR
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 SUNNY LANE RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:MS
Mailing Address - Zip Code:39039-9400
Mailing Address - Country:US
Mailing Address - Phone:662-571-2464
Mailing Address - Fax:
Practice Address - Street 1:1449 SUNNY LANE RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:MS
Practice Address - Zip Code:39039-9400
Practice Address - Country:US
Practice Address - Phone:662-571-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-26
Last Update Date:2011-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2243171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSTA2243OtherCOTA/L