Provider Demographics
NPI:1144923624
Name:KING-KERGE, MYRA ANN (LMSW)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:ANN
Last Name:KING-KERGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:ANN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:356 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-4401
Mailing Address - Country:US
Mailing Address - Phone:212-271-7192
Mailing Address - Fax:
Practice Address - Street 1:356 W 18TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4401
Practice Address - Country:US
Practice Address - Phone:212-271-7192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115799-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical