MEDICARE: DR. MYRTLE CHARISSE MEANS PHD

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	103T00000X	Psychologist	6301011889	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	68OE017280	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1710084801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRTLE CHARISSE MEANS PHD

Provider Business Mailing Address
First Line	:	11285 ELKINS RD STE D3
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-5835
Country	:	US
Telephone Number	:	313-574-6616
Fax Number	:

Provider Business Practice Location Address
First Line	:	23003 GREATER MACK AVE STE B
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-1965
Country	:	US
Telephone Number	:	313-574-6616
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/26/2019

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