Provider Demographics
NPI:1700139383
Name:MYERS WESLEY, NEVADA MARIE (MA, PC-IT)
Entity type:Individual
Prefix:
First Name:NEVADA
Middle Name:MARIE
Last Name:MYERS WESLEY
Suffix:
Gender:F
Credentials:MA, PC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:
Practice Address - Street 1:4570 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2145
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2140-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional