MEDICARE: DR. MYRNA MARIE LITTLE PH.D.

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	103TC0700X	Clinical Psychologist	22658	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22658	OTHER	TX	CLINICAL PSYCHOLOGY

General Provider Information

NPI Number	:	1346464245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRNA MARIE LITTLE PH.D.

Provider Business Mailing Address
First Line	:	4500 SHENANDOAH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75205-2030
Country	:	US
Telephone Number	:	214-522-8836
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 LYNDON B JOHNSON FWY
Second Line	:	SUITE 150
City	:	DALLAS
State	:	TX
Zip	:	75240-6467
Country	:	US
Telephone Number	:	972-233-0647
Fax Number	:	972-991-8966

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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