Healthcare Provider Details

I. General information

NPI: 1134709124
Provider Name (Legal Business Name): TYARA MYERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 MOCKINGBIRD LN APT 519
CHARLOTTE NC
28209-6225
US

IV. Provider business mailing address

1520 MOCKINGBIRD LN APT 519
CHARLOTTE NC
28209-6225
US

V. Phone/Fax

Practice location:
  • Phone: 717-419-9150
  • Fax:
Mailing address:
  • Phone: 717-419-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number4723
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: