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General NPI Number Information
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NPI Number | 1710084801
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Entity Type | Individual
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Provider Name | MYRTLE CHARISSE MEANS PHD
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Gender | Female
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/26/2019
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Provider Practice Location Address
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Address Line | 23003 GREATER MACK AVE STE B
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48080-1965
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Country | US
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Telephone | 313-574-6616
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Fax |
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Provider Business Mailing Address
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Address Line | 11285 ELKINS RD STE D3
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City | ROSWELL
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State | GA
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Zip | 30076-5835
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Country | US
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Telephone | 313-574-6616
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301011889
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License Number State | MI
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