Provider Demographics
NPI:1992869432
Name:MYERS, SUE ELLEN
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:MYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 GREYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1297
Mailing Address - Country:US
Mailing Address - Phone:573-642-5345
Mailing Address - Fax:573-642-0891
Practice Address - Street 1:8548 JADE ROAD
Practice Address - Street 2:
Practice Address - City:KINGDOM CITY
Practice Address - State:MO
Practice Address - Zip Code:65262
Practice Address - Country:US
Practice Address - Phone:573-642-5345
Practice Address - Fax:573-642-5345
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020065911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495246308Medicaid