Provider Demographics
NPI:1164226460
Name:HARGROVE, MYA
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:HARGROVE
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 1:1380 HERITAGE POINTE DR APT 203
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-6098
Mailing Address - Country:US
Mailing Address - Phone:336-803-2733
Mailing Address - Fax:
Practice Address - Street 1:1380 HERITAGE POINTE DR APT 203
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-6098
Practice Address - Country:US
Practice Address - Phone:336-803-2733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-03
Last Update Date:2025-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NCA21482101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program