Provider Demographics
NPI:1346727971
Name:MYERS, WHITAKER L (PSYD)
Entity type:Individual
Prefix:
First Name:WHITAKER
Middle Name:L
Last Name:MYERS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:L
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4714 ROTHMAN PL
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3097
Practice Address - Country:US
Practice Address - Phone:503-413-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
WI22082103T00000X
OR3288103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health