MEDICARE: MS. DORETHA JEAN MYERS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2625C	AR

General Provider Information

NPI Number	:	1154410793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DORETHA JEAN MYERS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 497
Second Line	:
City	:	AUGUSTA
State	:	AR
Zip	:	72006-0497
Country	:	US
Telephone Number	:	870-347-2534
Fax Number	:

Provider Business Practice Location Address
First Line	:	1028 N MISSOURI ST STE 6
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-2600
Country	:	US
Telephone Number	:	870-400-0263
Fax Number	:	870-400-0293

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/22/2022

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