Provider Demographics
NPI:1336934934
Name:GORTER, MYIA
Entity type:Individual
Prefix:
First Name:MYIA
Middle Name:
Last Name:GORTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MYIA
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2797 WEWATTA WAY UNIT 2043
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80216-3640
Mailing Address - Country:US
Mailing Address - Phone:231-944-8848
Mailing Address - Fax:
Practice Address - Street 1:2797 WEWATTA WAY UNIT 2043
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80216-3640
Practice Address - Country:US
Practice Address - Phone:231-944-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP0000001063193103TS0200X
CO24411966103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool