Provider Demographics
NPI:1154410793
Name:MYERS, DORETHA JEAN (LCSW)
Entity type:Individual
Prefix:MS
First Name:DORETHA
Middle Name:JEAN
Last Name:MYERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:
Practice Address - Street 1:1028 N MISSOURI ST STE 6
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2600
Practice Address - Country:US
Practice Address - Phone:870-400-0263
Practice Address - Fax:870-400-0293
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2625C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical