Provider Demographics
NPI:1871616052
Name:GENN, MYRA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:
Last Name:GENN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2502
Mailing Address - Country:US
Mailing Address - Phone:201-871-3818
Mailing Address - Fax:
Practice Address - Street 1:71 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3522
Practice Address - Country:US
Practice Address - Phone:201-871-9522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC001648001041C0700X
NYR00935111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GE654718Medicare ID - Type Unspecified