Basic Information
| Provider Information | |||||||||
| NPI: | 1063927390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | KAYE | ||||||||
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| Credential: | LCPC/C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 EUSTIS PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049015173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078732136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 66 STONE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073133455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2017 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | XL4995 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.